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ANTENATAL  PATHOLOGY  AND  HYGIENE 


WILLIAM    GKEEN    k    SONS 

BV    U0KRI80N   AND  OIBB   LIMITRD. 

Frhruury  1002. 


MANUAL 

OF 

ANTENATAL   PATHOLOGY 

AND    HYGIENE- 

THE    FOn'US 


J.  W.  BALLANTYNE,  M.D..  F.R.C.P.E..  F.R.S.Enix. 

LECTURER  OS  MIDWIFERY  AND  GYNECOLOGY,    MEDICAL  COLLEGE    KOR    WOMEN,    EDINBURGH  ; 

LECTURER    ON    ANTENATAL    PATHOLOGY    AND    TERATOLOGY   IN    THE    UNIVERSITY    OF 

EDINBURGH    (IWKI):  EXAMINER  IN   MIDWIFERY  IN  THE  UNIVERSITY  OF  EDINBURGH; 

ASSISTANT  PHYSICIAN,    ROYAL  JIATERNITY   HOSPITAL,    EDINBURGH  : 

HONORARY  FELLOW  OF  THE  GLASGOW  OBSTETRICAL  AND  GYNECOLOGICAL  SOCIETY, 

AND  OF  THE  AMERICAN  ASSOCIATION  OF  OBSTETRICIANS  AND  GYNECOLOGISTS. 


E  D  I  N  B  U  E  G  H 

WILLIAM     GREEN     cK:     SONS 

PUBLISHERS 
1902 


\-    V-' 


G7.NtRAL 


NAT  IS    ET 

NASGITUB.IS 


1:^309:^ 


Qui  in  ufcro  est,  pro  jam  naio  habe/ur 

LEGAL    MAXIM 


PREFACE 


1  HAD  hoped  within  the  compass  of  one  vohinie  to  have  presented  the 
whole  subject  of  Antenatal  Pathology  and  Hygiene.  It  was  mj 
purpose  to  have  included  not  only  the  physiology  and  the  diseases  of 
the  fojtus,  but  also  the  monstrosities  of  the  embryo  and  the  morbid 
states  of  the  germ.  I  have  been  compelled,  however,  to  devote  this 
volume  to  Fcetal  Physiology  and  Pathology  alone,  leaving  Teratology 
and  Morbid  Heredity  to  be  treated  in  a  separate  but  a  companion 
book,  which  may  be  regarded  as  Section  II.  of  this  Manual.  To  have 
done  otherwise,  would  have  been  to  swell  the  work  to  an  unwieldy 
size  and  to  delay  its  appearance  unduly. 

There  have  been  many  workers  in  this  field  of  research,  and  their 
work  has  lieen  most  fruitful ;  but  each  investigator  has  seldom  had  an 
opportunity  of  studying  more  than  a  few  specimens  of  foetal  disease 
and  deformity,  and  has,  in  consequence,  been  led  to  concentrate  his 
attention  upon  the  special  pathological  conditions  which  came  in  his 
way.  I,  on  the  other  hand,  have  had  the  extraordinary  fortune  to  be 
able  personally  to  examine  nearly  three  hundred  specimens,  embracing 
almost  all  the  leading  types  of  antenatal  morbid  states,  and  I  have 
thus  been  enabled  to  take  a  somewhat  wide  view"  of  the  whole  subject. 
Further,  many  other  workers  have  been  generously  ready  to  put  their 
own  material  at  my  disposal  for  inspection ;  and  I  have  also  read 
very  widely  the  literature  of  the  subject  and  of  allied  departments  of 
medicine  and  biology. 

I  began  this  work  in  a  spirit  of  something  very  like  active 
curiosity,  I  have  prosecuted  it  with  an  ever-deepening  interest,  and 
I  have  brought  it  thus  far  with  the  growing  sense  that  I  have  been 
dealing  with  a  suljject  of  tremendous  importance  for  the  future  of 
the  race  and  the  individual,  with,  in  fact,  jrrcre7itivc  medicine  in  its 
simplest  and  most  hopeful  because  in  its  earliest  aspects.  If  we  but 
knew  the  laws  which  govern  antenatal  health  and  the  causes  which 
produce  antenatal  disease  aud  death,  what  might  we  not  expect  the 
possibilities  of  Hygiene  to  grow  to  1 

In  writing  the  book,  I  have  honestly  tried  to  avoid  the  four  grounds 


viii  IM'.KIACK 

I  if  Jiiimaii  ignorance  set  ff>rth  so  long  ago  by  Eoger  Bacon:  trust  in 
ina(kM|iiate  autliority,  tlie  force  of  custom,  tlie  opinion  of  tlie  iuex- 
]pcrienced  crowd,  and  tiic  liiding  of  one's  own  ignorance  with  the 
jiarading  of  a  superficial  wisdom.  I  dare  not  liope  that  I  have 
always  succeeded ;  many  times  I  ought  perliaps  to  liave  said,  "  I 
'111  not  know,"  where  I  liave  set  forth  higli-sounding  theories:  l)ut 
I  have  done  what  seemed  at  tlie  time  possible. 

Only  one  or  two  furtlier  prefatory  sentences  need  be  added.  I 
iiave  avoided,  as  far  as  po.ssilile,  Imrdening  tlie  te.vt  witii  liibliograiiliical 
references,  and  have  endeavoured  rather  to  cite  articles  which  tliem- 
.selves  contain  full  lists  of  literature;  I  have,  for  instance,  often 
referred  to  coutril)uti<)ns  of  my  own,  which  iiave  appeared  elsewhere, 
wliidi  fulfil  tiiis  reipiirement.  In  the  Appendi.x  will  l)e  found  a  list 
of  my  writings  on  Antenatal  I'athology  and  cognate  subjects,  and  the 
nuiidiers  within  brackets  which  appear  in  the  text  refer  to  this  list. 
Tlie  historical  aspects  of  the  subject  have  scarcely  been  touched  :  they 
are  described  in  detail  in  the  first  volume  of  my  work.  The  Diseases 
i)f  the  Fo'.fns.  Tlie  illustrations  are  nearly  all  from  specimens  in  my 
own  collection;  but  for  Figs.  9,  24,  28,32-44,  and  50  I  am  indebted 
to  otlier  workers.  The  investigatirm  of  most  of  tiie  specimens  was 
carried  out  in  the  Laboratoiy  of  the  Itoyal  College  of  I'liysiciaiis, 
Edinldirgh. 

I  cannot  adiMpiately  express  my  indelitedness  to  my  friend,  Dr. 
Joiix  Tho.msox,  who  has  not  only  read  every  proof  with  painstaking 
solicitude,  but  has  also  given  me  advice  of  great  value  ami  that 
unstintedly. 

To  my  Publisher  my  best  thanks  go  freely,  and  they  are  well 
deserved,  for  he  has  constantly  endeavoured  to  meet  my  wisiies  with 
regard  to  every  detail. 

J.    W.   BALLANTVNK. 

21  Mei.vii.i.k  Stuket,  EiiiNmiKJii, 
January  i,  1902. 


CONTENTS 


BOOK   I 

ANTENATAL  IX  RELATIOX  TO  POSTNATAL  AND 
^    NEONATAL  rATnOL(JGY 

CHAPTER  I 

The  Novelty  of  Antenatal  Pathology  :  its  Definition,  Emergence,  and 
Literature  ;  Age-incidence  of  Morbid  Processes  ;  Divisions  of  Ante- 
natal Life  ;  Scheme  of  Antenatal  Life  ;  Suljdivisions  of  Antenatal 
Pathology  ;  Signs  and  Causes  of  Increased  Interest  in  Antenatal 
Pathology 

CHAPTER  II 

The  Relation  of  Antenatal  Pathology  to  the  other  Branches  of  Study  : 
Scheme  of  Relationships  ;  Relation  to  General  Pathology  ;  Relation  to 
the  Biological  Sciences — Anatomy,  Embryology,  Physiology,  Bt)tany, 
and  Zoology  ;  Relation .  to  the  Medical  Sciences — Obstetrics,  Public 
Health,  Pediatrics,  Medicine,  Psychology,  Dermatology,  Surgery,  Ortho- 
pedics, and  Medical  Jurisprudence ;  Relation  to  Gynecology  and 
Neonatal  Patholog}-  ....... 


CHAPTER  III 

The  Postponed  Effect  of  Antenatal  Pathology ;  the  Antenatal  Factor  in 
Gynecology ;  Traumatism,  Infection,  Antenatal  Conditions ;  the 
Antenatal  Factor  in  the  Morbid  Anatomy,  Symptomatology,  Etiology, 
Diagnosis,  Prognosis,  Therapeutics,  and  .lurisprudence  of  Gynecology  . 


CHAPTER  IV 

The  Immediate  Effect  of  Antenatal  Pathology  ;  the  Antenatal  Factor  in 
Neonatal  Pathology  ;  the  Neonatal  Period  of  Life ;  Physiology  of 
Neonatal  Life  ;  Physiological  Traumatism  of  Birth,  including  the 
Pressure  Effects  and  the  Separation  Effects  ;  Physiological  Readjust- 
ment at  Birth,  and  its  Influence  upon  the  Characters  of  the  Maladies 
of  the  New-ljorn  Infant ;  Anatonncal  Readjustment  ;  the  Antenatal 
Factor  and  its  Influence  upon  Neonatal  Pathological  Processes . 


CONTKNTS 


CHAITKR  V 


Types  of  Neonatal  Disease,  illustrating  the  Intrusion  of  the  Antenatal 
Factor :  (1 )  Inti-acranial  Traumatisms,  Cephalhiematoma  Ntona- 
toruni,  Facial  Panilysis,  Frarlurcs  of  the  Long  Bone?,  Dislocations; 
(2)  Intranatal  Infections,  (Ijilithalniia  Neonatorum,  Ha>matoma  of  the 
Stcrno-Mastoiil,  M;istitis  Neunatnruni      .  .  .  .  .44 

L'HAPTEl!  VI 

Tj-pes  of  Neonatal  Disease,  illustrating  the  Intrusion  of  the  Antenatal 
Factor  (aini.) ;  (3)  Neonatal  Infections,  Tetanus  Neonatorum,  Ery- 
sipelas Neonatorum,  Sepsis  Neonatorum,  Hiemoglohinuria  Neona- 
torum, Omphalorrhagia  Neonatorum  ;  (4)  Disturbed  Neonatal  Re- 
adjustments, Icterus  Neonatorum,  Mela-na  Neonatorum,  Keratolysis 
Neonatorum,  Pemphigus  Neonatorum,  Sclerema  Neonatorum,  Asphyxia 
Neonatorum,  Neonatal  Heart  Disease ;  Summary  .  .  .57 


BOOK  II 
THE  PATHOLOGY  AND  HYGIENE  OF  THE  FOiTUS 

CHAPTER  VII 

Diseases  of  the  Foetus  ;  General  Characters  of  Ffetal  Life  ;  Contrast  between 
Embryonic  and  Fa'tal  Life  ;  The  Neoftetal  Period ;  Anatomy  and 
Physiology  of  the  Neofirtal  Period  ;  External,  Internal,  and  Environ- 
mental I'hanges  in  the  Neufotal  Epoch  ;  Fivtal  (Irowth  and  Develop- 
ment at  the  Successive  Months  of  Intrauterine  Life  ;  Summary 

CHAPTER  VIII 

Anatomy  of  the  Mature  Fcetus.  Anatomy  of  the  Region  of  the  Head, 
Spine,  Neck,  Thorax,  Abdomen,  Pelvis,  and  Limbs.     Anatomy  of  the 

Umbilical  Cord,  Placenta,  and  Membranes  .... 

CHAPTER  IX 

Physiology  of  the  Fietus  :  General  Statements  ;  Sources  of  Information  ; 
Ftctal  Circulation,  Extra-corporeal  or  Placental,  Intra-corporeal  with 
Main  Current  and  Secondary  Circulations  ;  Cardiac  Activity,  Pecu- 
liarities ;  Pulse  ;  Blood  in  the  Fictus,  Characters  ;  Respiration  in  the 
Fietus         ......... 

CHAPTER  X 

Physiology  of  the  Fretus  (eonl.)  :  Tem]ierature  of  the  Futvis  ;  Chemical 
Com])05ition  of  Fietus,  Placenta,  and  Li(iuor  Amnii  ;  Nutrition  of  the 
Fatus,  by  Liquor  Amnii,  Umbilical  Vesicle,  and  Placenta  ;  Secretions 
of  the  Futus,  Hepatic,  Buccal,  IJastric,  Pancreatic,  etc.;  Excretions  of 
the  Fietus,  Intestinal,  Renal,  Placental :  Passjige  of  Substances  from"' 
Fietus  to  Mother ;  Internal  (Jlandular  Secretions  in  Fietus,  of 
Thymus,  Thyroid,  Suprarenal  Capsule,  and  Pituitary  Body  ;  Growth 
of  the  Fietus,  Determining  Factors  ;  Movements  of  the  Fictus  ;  Sensa- 
tion in  the  Fietus ........ 


CONTENTS 


CHAPTER  XI 

Fa'tal  Pathology  :  General  Principles.  ■  Scope  of  Fatal  Patliology  ;  Causes 
of  Limited  Knowledge  ;  Fn-tal  Morbid  States  ;  Classification  ;  Causes 
of  Peculiarities  of  Fa'tal  Diseases — (1)  Influence  of  Intrauterine 
Environment;  (2)  The  Placental  Factor;  (3)  The  Embryonic  Factor  .     17: 

CHAPTER  XII 

Types  of  Transmitted  Fcetal  Diseases  :  Frrtal  Variola  ;  Pathogenetic  Possi- 
bilities ;  Clinical  Peculiarities  ;  Diagnosis,  Prognosis,  and  Treatment. 
Fa-tal  Vaccinia  ;  Antenatal  Immunity.  Fcetal  Measles,  Scarlet  Fever, 
Erysipelas,  Parotitis,  Influenza,  Pertussis,  Relapsing  Fever,  Yellow 
Fever,  and  Cholera.  Ftetal  Typhoid  ;  Pathogenetic  Possibilities ; 
Widal  Test  in  the  Fcetus.  Fietal  Malaria ;  Observations ;  Patho- 
genetic Possibilities  .  .  .  .  .  .  .     18J 


CHAPTER  XIII 

Types  of  Transmitted  Ftctal  Diseases  :  Ftetal  Tubercle  ;  Evidence  of  its 
Existence  ;  Causes  of  its  Rarity  ;  Characters  ;  Baunigarten's  Theory  of 
Latency  ;  Non-tubercular  Manifestations  of  Antenatal  Tubercle  ;  Pro- 
phylaxis ;  Fcetal  Sepsis  ;  Fietal  Epidemic  Cerebro-spinal  Meningitis  ; 
Fi-etal  Purpura  ;  Fa'tal  Pneumonia  ;  Fujtal  Anthrax  ;  Foetal  Rheu- 
matic Fever  ........     ;206 

CHAPTER  XIV 

Types  of  Transmitted  F(otal  Diseases  :  Fa'tal  Syphilis  ;  Limitation  of  the 
Subject ;  Definitions  of  Infantile,  Neonatal,  and  Fcetal  Syphilis  ; 
Morbid  Anatomy,  General  and  Special  ;  Dystrophies  of  Antenatal 
Syphilis ;  Pathogenesis ;  Nature  of  the  Morbid  Agent ;  Modes  of 
Transmission  of  the  Syphilitic  Virus  ;  Effects  of  Fatal  S3-philis  ; 
Modifying  Influences ;  Treatment  .....     225 

CHAPTER  XV 

Types  of  Transmitted  Toxicological  Conditions :  Sources  of  Information  ; 
Problems  ;  Lead  Poisoning  ;  Mercurial  Poisoning  ;  Phosphorus  Poison- 
ing ;  Arsenical  Poisoning  ;  Poisoning  with  Copper  and  Sulphuric  Acid  ; 
Carbonic  Oxide  and  Coal  Gas  Poisoning ;  Effects  of  Chloroform  and 
Ether  ;  Morphin  Poisoning  ;  Tobacco  Poisoning  ;  Alcoholism  .  .     258 

CHAPTER  XVI 

Ill-defined  Morbid  States  of  the  Fcetus  :  in  Maternal  Eclampsia  ;  Cancer ; 

Diabetes:  Leukaemia;  Heart-Disease,  etc. ;  Conclusions  .  .     278 


CHAPTER  XVII 

Idioijathic  Diseases  of  the  Fcetus — Types  :  General  F<etal  Dropsy — Defini- 
tion, Clinical  History,  Symptomatology,  Morbid  Anatomy,  Etiology, 
Pathogenesis,  Diagnosis,  Treatment ;  General  Cystic  Elephantiasis  of 
the  Fa'tus — Definition,  Clinical  History,  Morbid  Anatomy,  Patho- 
genesis ;  Congenital  Elephantiasis  —  Definition,  Clinical  Hi.story, 
Symptomatology,  Physical  Signs,  Pathogenesis,  Treatment ;  Congenital 
Myxa'dema ;  Atrophic  States  of  the  Subcutaneous  Tissue 


CONTKNIS 


CHAPTKI!  .Will 


Idiopathic  Diseases  of  the  F.iaus  (rout.) :  Tvpes  of  Skin  Diseases  :  Fwtal 
Ichthyosis  (Grave  Form)— Definition,  Synonyms,  Clinical  History, 
Syiiiiitoiiialolony,  Apjiearances  (Macroscopic  and  Microscopic);  F(i-tal 
Jclithyosis  (Mild  I''orni) ;  Tylosis  Paliiiie  et  I'lantu- ;  F(utal  Keratolysis  ; 
Hypertricliosis  ((ingeiiita— Definition,  Synonyms,  Recorded  Cases, 
(,'linical  History,  I'atliogenesis ;  Localised  Form  of  Hypertrichosis; 
Congenital  Alopecia— Clinical  Characters,  Pathogenesis;  AntenaWl 
Pemphigus  or  Kpidermolysis  hiillosa  hereditaria  ;  Congenital  Absence 
of  Skin;  Acanthoma  or  Aninioiua  of  the  Skin    ....     ."JOC 

CHAPTER  XIX 

Types  of  Idiopatliic  Diseases  of  the  Fietus  (conf.) :  Diseases  of  the  Bones  ; 
Xomenclature  ;  Classification  ;  Tyjie  A,  Cliaracters  ;  Type  B,  Char- 
acters ;  Type  C,  Characters;  Type  D,  E.xternal  Apjiearances- Clinical 
History,  Pathology,  Pathogenesis  ;  Tyjie  K,  Characters ;   Bibliography     .'534 

CHAPTER  XX 

Types  of  Idiopatliic  Diseases  of  the  Fiotus  (ron(.)  :  Diseases  of  the  Ali- 
mentary System  :  Fivtal  Ascites,  Definition,  Clinical  Features  and 
History,  E.vternal  Appearances,  Morbid  Anatomy,  Etiology,  Pathology, 
Treatment;  Fetal  Peritonitis:  Congenital  Obiilerationof  the  Bile- 
Ducts,  Definition,  Clinical  History,  Symptomatology,  Morliid  Anatomv, 
Pathology,  Diagnosis,  Treatment ;  Congenital  Hy"pertro])hic  Stenosis 
of  the  Pylorus,  Definition,  Symjitomatology,  Jlorbid  Anatomy,  Patho- 
genesis, Treatment  .  .  .   '         .  .  ' .  .     3.-,,-, 

CHAPTER  XXI 

Types  of  Idiopathic  Diseases  of  the  Fo'tus  (cont.) :  Diseases  of  the  Circula- 
tory Apparatus  :  Fatal  Endocarditis— Relation  to  Congenital  Cardiac 
Anomalies,  Frequency,  Etiology,  Characters,  Diagnosis,  Associated 
Malformations,  Treatment ;  Antenatal  Atheroma  :  Congenital  Goitre  ; 
Definition,  Illustrative  Cases,  Morliid  Anatomv,  Clinical  Kesult.s, 
Treatment,  Pathology,  and  Ktiologv ;  Diseases"  of  the  Eespirator\- 
^.^■^te'i'      ■  •  ■  -       "     .  .  .  .  ".    :5e9 

CHAPTKI!  XXII 

Tyi)es  of  Idioiiathic  Diseases  of  the  Fu  tus  (mnt.)  :  Diseases  of  the  Urinarv 
A]iparatus  :  Fotal  Xepliritis,  Distension  of  tlie  Bladder,  Hyi>ertrophic 
Dilatation  of  the  Jiladder,  Hydronephrosis,  Cystic  Degeneration  of  the 
Kidneys  :  Di.'ieases  of  the  CJe'nital  Organs  :  Congenital  Prolapse  of  the 
Uterus  ;  Diseases  of  the  Nervous  System  :  Hydrocephalus  ;  Little's 
Disease  ;  Congenital  Chorea  ;  Friedreich's  Ataxia  ;  Tliomsen's  Di.-^ease  : 
Congenital  Clouding  of  the  Cornea  ....  :!7S 

CHAPTER  XXIII 

Traumatic  Morbid  States  of  the  Fietus  :  Fatal  Fractures,  ■\Vound.s.  and 
Dislocations;  Congenital  Amputations.  Diseases  of  the  Foial 
Anuexa  ;  Placental  Hiemorrhages  :  Fibro-Fattv  Degeneration  of  the 
Placenta  ;  Morbi.l  States  of  the  Umbilical"  Cord  ;  Hvdramnios 
—Definition,  Clinical  History,  Symptomatology,  Physical  Signs, 
Diagnosis,  Prognosis,  Pathology,  Patliogenesis,  'Treatn'ient ;  Oligo- 
hvdramnion  .  .  ' .  .  so-j 


CONTENTS  xiii 

I'AUK 

CHAPTER  XXIV 

lutrautcrine  Death  uf  the  Fcotus  ;  Mechauisui,  Firtal  Asphyxia  aucl 
Uneniia,  Rigor  Mortis,  Clinical  History,  Symptomatology,  Physical 
Examination,  Diagnosis,  Pathology  of  Maceration,  etc..  Abortion, 
Causes  of  Fatal  Death,  Treatment  " -tiW 

CHAPTER  XXV 

Diagnosis  of  Fulal  Morbid  States:  Difficulties  and  Scope;  Antenatal 
Diatrnosis,  Maternal,  Medical,  and  Reproductive  History,  Paternal  and 
Family  History,  Maternal  Symptomatology  and  Physical  Examina- 
tion, Physical  Examination  of  the  Fi.lus  ;  Intranatal  and  Postnatal 
Diagnosis  ...••■••• 

CHAPTER  XXVI 

Therapeutics  of  Fo'tal  Diseases:  Erroneous  Opinions;  yaUie  of  FieUil 
Life  Estimation,  Appreciation;  Therapeutic  Fcvticide ;  Possibilities 
of  Antenatal  Therapeutics  ;  Postnatal  Treatment  of  Antenatal  Morbul 
States ;  Intranatal  Hygiene  and  Treatment        .  -  •  .4.)! 

CHAPTER  XXVII 

Hygiene  and  Therapeutics  of  F.etal  Life  :  the  Hospitalisation  of  the 
Pregnant-  "Plea  for  a  Pre-Maternity  Hospital";  "Sanatom  de 
srossesse"  ;  Hygiene  of  Pregnancy  ;  Diet,  Occupation,  Exercise^  Dress, 
itc  ;  Medication  of  the  Fcetus,  in  Syphilis,  Placental  Disease,  >eryous 
Maladies,  Ha'mophilia  ;  Transmission  of  Immunity  ;  Ciermmal  ihera- 
peutics  ;  Conclusion  .■••••• 


Appendix.     List  of  Author's  Contributions 
Index  of  Authors     .  .  •  • 

Index  of  Subjects    .  .  •  ■ 


465 

489 
499 
507 


LIST  OF  ILLUSTRATIONS 


COLOURED   PLATES 

I.  Transverse  section  througli  neck  of  Full-time  Ftutus  at  level   of 

4th  Cervical  Vertebra        .  .  .  .  .  .108 

II.  Transverse  section  at  level  of  1st  Dorsal  Vertebra  in  same  Fujtus         108 

III.  Transverse  section  at  level  of  6th  Dorsal  Vertebra  in  same  Fretus         110 

IV.  Transverse  section  at  level  of  9th  Dorsal  Vertebra  in  same  Fcetus         110 
V.  Transverse  section  at  level  of  12tli  Dorsal  Vertebi'a  in  same  Fcetus         112 

VI.  Transverse  section   at   level   of  cartilage   between  2nd  and  3rd 

Lumbar  Vertebra?  .  .  .  .  .  .112 

VII.  Transverse  section  at  level  of  1st  Sacral  Vertebra  in  same  Fcetus        114 
VIII.  Transverse  section  at  level  of  4th  Sacral  Vertebra  in  .same  Fatus         114 
IX.  Transverse   section  at  level  of  3rd  Coccygeal  Vertebra  in  same 

Fcetus         .  .  .  .  .  .  .  .116 

X.  Liver  from  case  of  Fcetal  Syphilis    .....        233 

XL  Vertical  Mesial  section  of  Fa?tus  with  F(.L'tal  Bone  Disease  (Type  B)        339 
XII.  Vertical  Lateral  section  of  trunk  of  Fcutus  with  Ascites  and  Dis- 
tension of  Bladder  .  .  .  .  .        '     .         355 

XIII.  Vertical  Mesial  section  of  Pelvis  of  Infant  with  Prolapsus  Uteri   .         355 

XIV.  Vertical  Mesial  section  of  Macerated  Ftctus  .  .  .422 


FIGURES    IN    THE   TEXT 

1.  Divisions  of  Antenatal  Life      ......  8 

2.  Scheme  of  Antenatal  Life  .  .  .  .  .  .11 

3.  Relations  of  Antenatal  Pathology         .  .  .  .  .18 

4.  Scheme  of  Morbid  Factors         ......  24 

5.  Cephalhieraatoma  and  Facial  Paralysis   in   New-born  Infant  (left 

side)  .........  47 

6.  7.  Microscopic  appearances  of  Desquamation  of  Cuticle  in  New-born 

Infant,  High  and  Low  Powers  .....  73 

8.  Microscopic  appearancees  of  Skin  in  Sclerema  Neonatorum     .  .  75 


LIST    OF    ILLUSTRATIONS 


9. 

10. 

n. 

12. 
13. 
14. 
1.5. 
10. 
17. 
18. 

ly. 

20. 
21. 
22. 
23. 
24. 
25. 
20. 
27. 
28. 
29. 
30. 
31. 
32, 
34. 

3J. 
30. 
37. 
38. 
39. 
40. 
41- 
45. 
40. 
47. 
48. 
49. 
50. 


Embryo  of  38  days — "  Transition  Organi.sni  "—After  His 

Fa'tus  of  50  clays  (circa)  ..... 

Scheme  of  Ftrlal  Growtli  in  Length      .... 

Scheme  of  Fdtal  Growlli  in  Weiglit      .... 

Scheme  of  Phicental  (irowth  in  Weiglit 

Scheme  of  Relative  Devcloimient  of  various  jiarts  of  Ftetus    . 

Outline  of  Unmouldeil  Fcital  Head      .... 

Outline  of  Head  of  New-born  Infant    .... 

Sagittal  Mesial  section  of  Full-time  Fa^tus 

Lateral  Vertical  .section  of  Full-time  Fa'tus 

Coronal  section  of  Head  of  Full-time  Fa'tu.s,  through  orbits  . 

Coronal  section  of  Head  of  Full-time  Fcitus,  through  ears 

Vertical  Sagittal  section  of  Pelvis  of  Male  Fulltime  Fotus   . 

Vertical  Sagittal  section  of  Pelvis  of  Female  Full-time  Fcetus 

Pelvic  Viscera  of  Si.\  Months'  Female  Futus   . 

Scheme  of  Fietal  Circulation.     After  W.  Preyer 

Sphygniogra])liic  Tracing  from  Infant,  5  minutes  after  Birth 

Sphygmographic  Tracing  from  Infant,  0  days  old 

Placenta  with  Persistent  Unil)ilical  Vesicle  and  Vitelline  ^'essels 

Fcetal  Variola.     After  Laurens  .... 

Section  of  Tricuspid  Valve  of  Heart  from  case  of  Fa-t;il  Endocarditi 

Vertical  Mesial  section  of  Fii-tus  with  General  Dropsy 

Appearances  of  Head  and  Face  of  Fcetus  with  General  Dropsy 

33.  Cystic  Elephantiasis  in  the  Fa'tus.    After  A.  Meckel 

Infant  with  Congenital  Elephantiasis  of  right  lower  limb.     After 

Moncorvo  .  .  .... 

Fa'tal  Ichtliyosis.     After  Straube         .... 

Fatal  Ichthyosis.     After  Kyber  .... 

Skin  of  Palm  of  Hand  in  Fatal  Ichthyosis.     After  Kyber 
Sections  of  Skin  in  Fatal  Ichthyosis,  Chest  and  Head.    After  Kybc 
Skin  of  Normal  Infant.     After  Caspary 

Skin  of  Infant  with  Ichtliyosis  of  Minor  Degree.     After  Caspary 
44.  The  Hairy  Family,  Vo7i  Ambriis      .... 

Infant  with  Acanthoma  or  Amnioma  of  the  Hairy  Scalji 
Microscopical  Appearances  of  Acanthoma  or  Amnioma 
E.vternal  Appearances  of  Foitus  with  Bone  Disease  (Type  B) 
E.xternal  Appearances  of  Fa'tus  with  Bone  Disease  (Type  C) 
Appearances  of  Lower  Limbs  and  Pelvic  Region  of  the  same  . 
E.Kternal  Appearances  of  Fatus  with  Bone  Disease  (Type  D).     Afte 

Villa 

External  Appearances  of  Fa'tus  with  Bone  Disease  (Type  E) 

External  Appearances  of  Fietus  with  Ascites  . 

Microscopic  Appearances  of  section  of  Abdominal  Wall  fioMi  same 

Apjiearances  of  External  Genitals  of  same 

External  Ai>pearances  of  Fatus  with  Congenital  Goitre 


80 

80 

94 

95 

90 

97 

100 

10 1 

102 

103 

104 

105 

117 

lis 

119 

128 

138 

138 

155 

191 

197 

291 

293 

299 

302 
309 
310 
311 
312 
310 
317 
322 
331 
332 
338 
341 
341 

347 
351 
359 
300 
301 
374 


.1 


MANUAL    OF 

ANTENATAL    PATHOLOGY    AND 

HYGIENE 


BOOK  I 

ANTENATAL   IN   EELATION   TO   POSTNATAL   AND 
NEONATAL  PATHOLOGY 

CHAPTER   I 

The  Novelty  of  Antenatal  Pathology  ;  Its  Definition,  Emergence,  and  Literature  ; 
Age-incidence  of  Morbid  Processes ;  Divisions  of  Antenatal  Life  ;  Scheme 
of  Antenatal  Life ;  Subdivisions  of  Antenatal  Pathology ;  Signs  and 
Causes  of  Increased  Interest  in  Antenatal  Pathology. 

Antenatal  Patholocjy  is  to  some  extent  a  new  department  of  medi- 
cine. With  it,  however,  as  with  many  other  new  things,  the  novelty 
consists  more  in  the  point  of  view  froua  which  the  subject  is  regarded, 
and  in  the  mode  of  considering  it  which  is  adopted,  than  in  the  nature 
of  the  subject  itself.  From  the  earhest  times  congenital  diseases  and 
monstrosities  and  morbid  predispositions  have  been  known,  and  to 
some  extent  studied ;  but  it  is  only  within  recent  years  that  the 
information  gathered  together  regarding  them  has  been  systematised, 
and  that  monstrosities  as  well  as  diseases  have  been  shown  to  be  capable 
of  scientific  investigation,  and  to  be  possessed  of  practical  interest. 

Antenatal  Pathology,  therefore,  is  new,  but  only  in  a  limited 
sense.  Nevertheless,  Antenatal  Pathology,  more  perhaps  than  any 
other  branch  of  medical  study,  requires  an  introduction  which  shall 
be  also  an  explanation.  To  some  extent  it  may  be  thought  to  need 
a  vindication — to  be  in  want  of  a  reason  for  its  existence.  Lately 
unborn  among  the  sciences,  it  has  but  recently  seen  the  light,  and, 
like  all  new-born  things,  has  a  hold  on  life  which  is  uncertain.  Full, 
no  one  can  doubt,  of  great  possibilities,  if  it  be  able  to  reach  maturity  ; 
but  apparently  so  weak  as  to  suggest  to  the  careless  observer  little 
chance  of  that.  Yet  not  so  long  ago  was  bacteriology — even  as 
Antenatal  Pathology  now  is — provoking  the  criticism,  that  the  study 


2  ANTKNATAI.    I'A  TllOLOdV    AM)    HVdlKNE 

of  organisiiis  so  minute  as  t<i  need  tlie  niicroscoiie  fur  tlieir  detection 
was  hardly  likely,  most  unlikely  indeed,  to  jirove  of  licneKt  to  the 
human  race,  yet  pregnant  all  the  while  with  surgical  antisepsis  and 
asepsis,  and  with  tlie  marvels  of  serum  therajieutics.  Antenatal 
Pathology,  too,  deals  with  small  organisms — to  wit,  the  little  fu'tus, 
the  tiny  embryo,  the  altogether  microscopic  uvum  and  spermato- 
zoon. It  thus  merits  the  same  condemnatiiiu  ;  it  may  receive  a  like 
justification. 

Definition   of  Antenatal   Pathology. 

Antenatal  I'athology  is  concerned  with  all  tlie  morliiil  processes 
which  act  upon  the  organism  before  birth,  and  with  the  ehecls  which 
they  produce  by  their  action.  In  a  narrow  sense  only  can  its  limits 
be  defined.  It  deals  with  the  pathology  of  the  individual  during  his 
fcetal  and  embryonic  existence,  and  in  this  res]iect  may  be  regarded 
as  the  pathology  of  intrauterine  life,  and  have  the  period  of  its 
action  limited  to  ten  lunar  months ;  but  manifestly  any  such  limit- 
ation is  unsupported  liy  the  known  facts.  It  cannot  be  doubted 
that  pathological  agencies  are  at  work  even  before  the  occurrence 
of  impregnation,  and  that  they  produce  their  ellects  upon  the  special- 
ised reproductive  cells  before  these  have  united  together,  sperm 
with  germ,  to  form  the  first  rudiments  of  the  individual.  Further, 
the  great  doctrme  of  the  continuity  of  the  germ  plasm  ])ushes  back 
the  terminus  a  quo  of  the  action  of  morljid  agents  beyond  the 
innuediate  progenitors  of  the  individual,  ami  compels  the  student  of 
Antenatal  Pathology  to  take  into  account  the  medical  history  of 
earlier  ancestors.  Just  as  Ijirth  marks  not  a  beginning  liut  a  stage 
in  the  life  of  the  indiviilual,  so  impregnation  marks  not  a  beginning 
but  a  stage  in  the  life  of  the  family.  Again,  ami  with  regard  now  to 
the  terminus  ad  quern.  Antenatal  Pathology  cannot  be  said  to  end 
with  the  close  of  intrauterine  life,  for  it  is  imjiossible  to  prevent 
the  morbid  processes  which  occur  before  birth  from  projecting  their 
effects,  often  with  disastrous  results,  far  into  the  life  that  is  after 
birth.  It  is  this  projection  of  the  antenatal  into  the  jiostnatal  which 
hinders  the  formation  of  an  e.xact  definition  of  Antenatal  I'athology. 
It  is  necessary  to  think,  not  only  of  the  effects  of  the  action  of  morbid 
agents  upon  the  organism  still  in  utero,  but  also  of  the  results  which 
they  produce  upon  the  individual  in  extrauterine  life.  Incidentally 
it  may  be  remarked  that  this  fact  constitutes  one  of  the  most  cogent 
arguments  in  proof  of  the  practical  importance  of  the  study  of 
Antenatal  Pathology.  Since  it  has  come  to  be  recognised  that  all 
infants  have  not  the  same  starting-point  in  their  life  race,  so  it  has 
been  borne  in  upon  the  jmictical  physician  and  surgeon  that  it  may 
be  profitable  to  investigate  the  conditions  which  hinder  them. 
Truly  it  matters  little  that  the  projection  of  the  antenatal  into  the 
postnatal  has  interfered  with  the  exactness  of  a  definition,  so  long 
as  it  has  comjiellcd  the  attention  of  a  medical  public,  until  now 
perhaps  Init  slightly  inclined  thereto.  "Where  the  profession  has 
hung  timidly  back,  the  modern  novelist  has  jjlunged  boUlly  in,  and 
has  not  hesitated  to  deal  with  any  or  all  the  problems  of  Antenatal 


EMERGENCE  OF  ANTENATAL  PATHOLOCiV      3 

Pathology,  from  the  trausmission  of  syphihs  and  the  causation  of 
malformations,  to  the  predisposition  to  tuberculosis  and  the  inherited 
tendency  to  insanity.  It  need  hardly  be  said  that  the  effect  upon 
the  public  mind  has  not  always  been  for  good.  Disaster  stares  tlie 
mariner  in  the  face  who  sets  out  without  rudder  or  compass.  The 
medical  profession  must  in  this  matter  provide  the  general  public 
with  a  rudder,  perchance  it  may  yet  be  able  to  supply  also  the 
compass. 

Emergence  of  Antenatal  Pathology. 

It  is  clear,  then,  that  Antenatal  Pathology  has  a  novelty,  wliich 
consists  not  so  much  in  the  facts  with  which  it  has  to  deal,  as 
in  the  way  in  which  they  are  approached,  and  in  the  standpoint 
from  which  they  are  surveyed.  It  sets  forth  a  new  manner  of 
looking  at  old  facts.  The  new  manner  is  the  scientific  :  and  it 
has  been  rendered  possible  by  the  marked  advances  that  have  taken 
place  in  the  other  departments  of  medicine  and  biology.  As  has 
been  aptly  said  by  Professor  A.  E.  Simpson :  "  Antenatal  Pathology 
is  one  of  the  last  provinces  of  medicine  to  have  emerged  from  a 
kind  of  mediaeval  wonderland  into  the  realm  of  science."  This  is 
particularly  true  of  a  large  and  very  characteristic  subdivision  of 
the  subject,  which  has  been  named  Teratology,  dealing,  as  it  does,  with 
monstrosities  {tcraia)  and  their  mode  of  origin.  It  may  be  doubted 
whether  Teratology  has  yet  emerged  from  its  "  mediaeval  wonder- 
land." The  genera]  public,  it  must  at  once  be  adnntted,  looks  upon 
monstrosities  to-day  very  much  in  the  same  way  as  did  the  general 
public  and  the  profession  as  well  in  the  Middle  Ages ;  but  it  is  a 
trifle  more  tolerant  of  the  progenitors  of  such  prodigies.  In  this 
respect,  however,  the  general  public  is  not  to  be  too  severely 
censm'ed,  for  it  is  unfortunately  true  that  many  medical  men, 
when  they  meet  with  specimens  of  antenatal  malformation,  describe 
them  in  a  fashion  that  they  would  certainly  never  employ  if  the 
case  were  one  of  nervous  disease  or  tumour,  using  a  terminology 
which  might  with  reason  be  called  mediaeval.  A  monstrous  fcetus 
may,  it  is  true,  resemble,  although  the  likeness  is  often  far  to 
seek,  a  dog  or  a  cat  or  an  ape  ;  but  in  describing  no  other  patho- 
logical specimen  would  it  be  considered  as  sufficient  or  satisfactory 
to  rest  content  with  such  a  comparison.  Yet  in  many  reported  cases 
of  monstrosity  the  morbid  anatomy  is  dismissed  with  a  brief  refer- 
ence to  a  dog-like  or  frog-like  look,  while  many  lines  of  print  are 
devoted  to  the  story  of  an  alleged  maternal  impression  during  the 
pregnancy  of  which  the  malformed  infant  was  the  product.  If  this 
be  so  in  the  profession,  what  reason,  then,  is  there  for  wonder  if  in 
the  public  mind  a  veil  of  mystery  shroud  tlie  birth  of  a  monstrous 
fcetus  '^ 

Literature  of  Antenatal  Pathology. 

It  has  to  be  borne  in  mind  that  Antenatal  Pathology  has  not 
emerged  directly  out  of  the  ignorance  of  the  Middle  and  l3ark  Ages ; 
it  has  not  sprung  full  of  life  immediately  out  of  dead  superstitiims 


4  ANTKNATAL    PA  THOI.CXiY   AND    HYGIENE 

and  curious  i|uestioiiiiig.s  uf  the  folk-lore  kind.  Eather  has  it  arisen 
out  of  a  sea  of  books  and  monograplis,  out  of  u  perfect  ocean  of 
literature.  In  this  ocean,  as  may  well  be  imagined,  there  is  much 
that  is  of  little  worth ;  nevertheless,  the  searcher  will  now  and 
again  bring  up  in  his  net  something  that  is  of  j>rime  import.  In 
it.s  alnsuuil  depths  are  the  teratological  records  of  Chaldea  (70),' 
written  in  cuneiform  character  on  the  Ijrick  tablets  of  the  great 
mound  of  Koyunjik  near  tiie  Tigris,  containing  a  long  list  of  mon- 
strous infants,  with  the  divinatory  meaning  of  each  one  of  them : 
for  teratoscopy  had  reached  a  high  development  in  Ijabylonia,  and 
the  fall  of  a  kingdom,  the  winning  of  a  battle,  and  the  occurrence 
of  a  famine,  and  nmch  else,  were  foretold  from  the  birth  of  a 
malformed  fu'tus.  Vanisiiing  traces  of  the  teratological  occur- 
rences of  primitive  times  among  primitive  peoples  are  also  to  be 
found  in  the  deformed  deities  which  the  heathen  ignorantly  wor- 
ship, and  in  the  folk-hn-e  of  many  nations.  Of  all  the  valualde 
things  rescued  from  the  bibliographic  sea  of  teratological  literature, 
nothing  is  of  just  so  much  value  as  the  part  of  Aristotle's  works 
which  deals  with  monstrosities,  both  human  and  of  animals.  In 
the  "  Generatio "  and  the  "  Historia  AnimaHum "  is  displayed  a 
knowledge  of  the  meaning  and  cause  of  malformations  such  as 
was  not  equalled  in  later  history  till  the  times  of  the  Saint- 
Hilaires,  in  tlie  dawn  of  the  nineteenth  century.  In  the  writings 
that  have  come  down  to  us  under  the  name  of  Hippocrates,  there 
is  not  much  tliat  concerns  monstrosities,  but  there  are  admirable 
descriptions  of  congenital  dislocations,  and  disquisitions  on  morbid 
heredity,  which  cannot  fail  to  interest  the  antenatal  pathologist 
(83).  These  things,  however,  are  all  deep  down  in  the  ocean  of 
literature,  and  it  is  not  till  we  come  near  to  the  surface  tliat 
there  is  again  much  of  value  to  reward  our  search.  From  300 
B.C.  to  1700  A.D.,  works  on  monstrosities  (it  is  imjiossible  to  men- 
tion works  on  ftetal  disease  and  morbid  predisposition,  for  they 
did  not  exist)  have  a  value  which  is  quite  apart  from  the  cases 
and  specimens  which  are  described  in  them ;  they  throw  interesting 
side-lights  upon  the  manners,  customs,  and  beliefs  of  the  times ;  but 
as  to  scientific  Teratology  they  are  singularly  dark.  During  these 
centuries  deformed  fictuses  took  their  place  alongside  comets,  earth- 
quakes, showers  of  frogs,  mock  suns,  and  the  like :  aiul  were  com- 
monly regarded  as  prodigies,  or  as  warnings  of  impending  evil,  or 
as  manifestations  of  the  divine  anger.  From  the  lieginning  of  the 
eighteenth  century  scientific  works  on  monstrosities  began  to  appear, 
and  have  continued  to  appear,  until  now  one  may  easily  gather  together 
many  hundreds  of  treatises,  atlases,  monographs,  theses,  and  articles 
dealing  with  teratological  subjects.  In  1702,  also,  there  appeared 
the  first  separate  work  treating  of  ftctal  diseases,  as  distinguished 
from  monstrosities,  the  treatise  namely  of  Diittel,  entitled  "De 
morbis  fo'tuum  in  utero  materno,"  and  presented  for  the  degree  of 
medicine  in  the   University  of  Halle,  under  the  presidency  of  F. 

'  The  figures  within  parentheses  refer  to  the  bibliographical  list  of  the  author's 
published  works. 


AGE-INCIDEXCK   OF   MOURIIJ    I'ROCKSSES  5 

Hoffmann  (66).  Since  then  the  study  of  tlie  diseases  of  the  foetus, 
as  distinct  from  tlie  monstrosities,  has  made  great  advances,  until 
now  there  has  been  accumulated  a  large  library  of  books  bearing 
on  this  subdivision  of  Antenatal  Pathology.  Still  more  near  the 
surface  of  the  ocean  of  literature  (to  return  for  a  moment  to  our 
comparison)  lie  the  works  in  which  the  morbid  predispositions  to 
diseases  and  deformity,  and  the  mysterious  phenomena  of  heredity, 
are  considered ;  in  them  is  to  be  found  much  that  is  of  value,  along 
with  much  that  is  at  the  best  hypothetical. 

This,  then,  is  the  literature  of  Antenatal  Pathology,  or  rather  it  is 
the  literature  upon  which  it  is  hoped  that  the  subject  of  Antenatal 
I'athology  may  yet  be  built  up ;  for  few,  if  any,  attempts  have  been 
made  to  bring  together  the  monstrosities,  and  the  fcetal  diseases, 
and  the  morbid  predispositions,  and  treat  them  as  subdivisions  of 
one  separate  and  self-contained  department  of  medicine.  It  is  in 
this  that  the  novelty  of  Antenatal  Pathology  consists ;  the  subject  is 
surveyed  from  a  new  point  of  view,  with  a  vastly  widened  horizon. 

The  Age-Incidence  of  Morbid  Processes. 

It  is  conceivable  that  morl.iid  influences  may  act  upon  the 
individual  during  thi-ee  epochs  in  his  existence  :  they  may  act  after, 
during,  or  before  birth.  In  other  words,  their  influence  may  be 
exerted  in  postnatal,  in  intranatal,  or  in  antenatal  life.  The  results 
of  their  action  vary  with  the  period  during  which  they  act,  and  hence 
it  conies  that  there  is  a  postnatal,  an  intranatal,  and  an  antenatal 
subdivision  of  pathology.  It  goes  without  remark  that  it  is  about 
postnatal  pathology  that  most  is  known,  for  from  birth  up  to  death 
morbid  causes  are  seen  at  work,  and  their  effects  are  patent  to  all. 
Injuries,  poisons,  microbes,  and  parasites  all  play  a  part  in  producing 
the  numerous  and  varied  changes  in  the  structure  and  functions  of 
the  body  so  fully  described  in  medical  and  surgical  text-books. 
When  pathology  is  spoken  of,  it  is  usually  postnatal  pathology  tliat 
is  meant. 

Even  in  postnatal  pathology  the  age-incidence  of  morbid  processes 
can  be  i-ecognised  as  an  important  subdividing  factor  ;  differences 
tliere  are  between  the  pathological  changes  which  are  characteristic 
of  advanced  age  and  those  which  occur  in  adult  life,  or  in  childhood, 
or  in  infancy.  The  rheumatism  of  childhood,  for  instance,  is  very 
different  in  its  clinical  manifestations  from  that  of  adult  life.  In  the 
former,  erythema  marginatum  and  papulatum,  painless  subcutaneous 
nodules  situated  over  the  bony  prominences  of  the  knee,  elbow,  ankle, 
and  spine,  and  endocarditis  and  chorea  are  marked  symptoms ;  while 
acute  pain  and  tenderness  in  the  joints,  high  fever,  and  profuse 
sweating  are  often  entirely  absent.  In  the  rheumatism  of  adult  life, 
on  the  other  hand,  erythemata,  nodules,  and  cliorea  are  uncommon, 
while  grave  arthritic  developments  are  frequent.  Heart  disease  also 
differs  in  its  characters  according  as  it  is  met  with  in  the  child  or 
adult ;  and  there  is  the  typical  senile  heart. 

The  differences,  however,  which  mark  off  these  epochs  of  post- 


AM  I'.NATAI,    1'A111()I.()(;Y    AND    llVdll'.NE 


iiiital  patholugifal  life  frmii  inie  ancjllier  are  small  when  contiasttil 
with  the  characters  whicli  serve  to  distinguish  neonatal  from  post- 
natal niorhid  chani^es,  ami  very  small  indeed  when  jjut  alongside  the 
ileep-seated  diversity  of  antenatal  jiathology.  The  difi'erences  found 
in  the  diseases  of  tiie  new-born  have  given  origin  to  a  separate  nomen- 
clature for  them,  a  neonatal  nosology ;  and  we  speak  of  icterus 
neonatorum,  sy])hilis  neonatorum,  and  mela-na  neonatorum  as  if  they 
were  superficially  difl'erent,  at  any  rate,  from  the  jaundice  and  the 
sypliilis  and  the  mehena  of  the  adult.  But  such  dissimilarity  exists 
between  the  pathological  phenomena  which  occur  before  birth,  and 
those  which  are  met  witli  after  it,  as  to  suggest  essential  diHerences 
in  mxture  and  causation.  This  is  specially  true  of  teratological 
phenomena.  They  are  startlingly  unlike  anything  else  in  the  whole 
range  of  piathology.  Jt  is  to  this  peculiarity  more  than  to  any  other 
that  Teratology  owes  the  isolated  position  that  it  has  so  long  occupied. 
Like  Corea  among  the  nations  has  Teratology  been  among  the  sciences : 
a  hermit  kingdom,  a  hermit  science  !  To  the  onlooker  it  has  seemed 
as  if  neither  had  any  part  to  play  outside  its  own  narrow  limit.s.  Yet 
is  the  whilom  hermit  subject  capable  of  profoundly  influencing  the 
other  departments  of  medical  research  and  of  being  influenced  by 
them.  As  the  subject  opens  out  we  shall  see  in  detail  what  these 
age-incidence  ditlerenees  in  pathology  consist  in  ;  meanwhile,  it  may 
be  repeated  that  from  this  standpoint  there  is  a  pathology  of  post- 
natal life,  of  intranatal  life,  and  of  antenatal  life. 

The   Divisions  of  Antenatal   Life. 

On  first  thoughts,  the  nine  months  of  intrauterine  life  and  the 
twelve  hours  of  intranatal  transition  seem  small  and  of  little  imp(irt 
in  comparison  with  the  threescore  and  ten  years  to  which  it  is 
expected  that  postnatal  life  may  be  prolonged.  It  is  doubtful,  how- 
ever, if  any  twelve  hours  after  birth  are  just  so  full  of  possibilities, 
physiological  and  pathological,  as  is  the  time  during  which  the  foHus 
is  passing  through  the  maternal  canals ;  and  it  is  certain  that  no 
period  of  nine  mouths  in  childhood,  in  adult  life,  or  in  old  age  is  so 
replete  with  occurrences,  so  diverse  in  kind,  and  of  such  far-reaching 
importance  as  is  that  spent  by  the  unborn  infant  in  utero.  Thei'e 
is  an  intensity  and  a  variety  in  the  processes  of  antenatal  life  which 
have  no  equal  at  any  other  time.  Therefore,  notwithstanding 
the  shortness  of  intrauterine  existence,  it  has  become  necessary  to 
sulidivide  it  into  at  least  three  periods,  and  between  these  there  is  the 
same  deep-seated  diversity  as  that  wiiich  marks  off  antenatal  life 
from  the  rest  of  life.  Further,  it  is  no  exaggeration  to  say  that  few 
medical  men  have  a  very  clear  conception  of  the  ]irogress  of  events 
during  antenatal  life.  The  drama  of  embryonic  and  ftetal  develop- 
ment and  growth  is,  so  to  speak,  going  on,  but  the  curtain  has  not 
been  rung  up,  and  the  spectators  get  only  confu.sed  impressions  from 
the  swaying  of  the  drop-scene  and  from  vague  sounds,  excursions  and 
alarms,  coming  from  behind  it :  yet  no  one  doubts  the  existence  of 
great  activity  post  cortina^n  thcatri,  and  some  from   superior  know- 


DIVISIONS    OF   ANTEXATAL   LIFE  7 

leds^'e  can  judge  how  preparations  are  progressing.  The  accompanying 
scheme  of  the  divisions  will  serve,  taken  in  conjunction  with  the 
descriptive  notes,  to  give  to  the  mind  a  somewhat  clearer  conception 
of  the  chronology  of  the  period  of  preparation  for  the  great  events  of 
postnatal  life  :  it  ^vill  take  the  place  of  the  prologue  in  explaining  the 
action  of  the  to  be  enacted  drama  (Fig.  1). 

In  constructing  the  scheme  1  have  employed  the  "  space-for- 
time  ■'  method  introduced  into  medical  case-recording  by  Mr.  Jonathan 
Hutchinson,  and  described  by  him  in  1896  {Aivh.  Stirr/.,  1896,  vol.  vii. 
p.  199).  By  this  plan,  all  periods  of  time  are  repu'esented  in  the 
schedule  by  equal  e.xtents  of  space,  no  time  is  left  out,  and  the  whole 
duration  of  the  antenatal  epoch,  with  its  various  events  in  their  proper 
places,  is  brought  correctly  before  the  eye.  Each  interspace  in 
the  scheme  represents  a  week  ;  and  as  pregnancy  lasts  normally  for 
forty  weeks,  there  are  forty  interspaces  intervening  between  its 
beginning  and  end ;  but  as  the  month  following  birth  is  much 
influenced  by  what  has  happened  before  birth,  and  is,  indeed,  a 
transition  period  between  antenatal  and  postnatal  life,  it  also  has 
found  a  place  in  the  scheme,  and  has  four  interspaces.  Above  the 
neonatal  period  are  to  be  imagined  the  many  spaces  indicating  the 
many  weeks  of  postnatal  existence.  The  great  physiological  event  of 
neonatal  existence  is  the  adaptation  of  the  organism  to  its  new  environ- 
ment ;  the  fcetus  is  suddenly  brought  into  surroundings  which  demand 
the  functional  awakening  of  several  organs  which  have  in  intrauterine 
life  been  almost  if  not  quite  dormant,  and  structures  which  have  been 
active  have  to  atrophy,  lie  absorbed,  or  be  utilised  for  other  than  their 
antenatal  purposes.  Extrauterine  life  is  linked,  as  it  were,  to  intra- 
uterine by  this  short  period  of  the  new-born  infant. 

Immediately  Ijefore  the  neonatal  period  (below  it,  therefore,  in  the 
schedule ),  and  separated  from  it  by  the  event  of  birth  (indicated  in 
the  schedule  by  a  thick  lilack  line),  is  the  fatal  epoch.  This  occupies 
by  far  the  largest  part  of  pregnancy ;  without  reckoning  the  neofo^tal 
period,  it  extends  from  the  eighth  to  the  fortieth  week,  or  thirty-two 
weeks.  During  its  progress  the  organism  shows  its  vitality  chiefly 
by  growth  along  lines  which  have  been  already  definitely  laid  down. 
In  this  respect  it  resembles  the  postnatal  periods  of  infancy  and 
youth.  It  is  true  that  the  intrauterine  environment  has  very  dis- 
tinctive and  peculiar  characters — the  unborn  infant  exists  in  a  fluid 
medium  of  practically  constant  temperature,  it  is  protected  from 
traumatism  by  the  maternal  structures,  and  it  is  shut  in  from  the 
light ;  further,  the  fcetus  has  several  of  its  organs  almost  inactive, 
and  its  most  important  and  most  active  organ,  the  placenta,  is  extra- 
corporeal ;  nevertheless,  the  chief  phenomenon  of  fcetal  life  is  growth, 
rapid  and  continuous,  along  lines  already  indicated.  Within  seven 
(calendar)  months,  which  is  the  length,  roughly  speaking,  of  fcetal 
life  in  the  human  subject,  the  organism  increases  from  a  structure 
1  in.  in  length  to  one  measuring  20  in.,  and  its  increase  in  weight 
is  from  1  oz.  to  7  or  8  lbs. 

During  the  cmhryonic  period  of  antenatal  life,  which  may  be  said 
to  begin  with  the  laving  down  of  the  first  rudiments  of  the  embryo 


8  ANT]:NAT.\I,    l-ATllOUKiV    AM)    HV(;iKNK 


FIG.   1. 

THE    DIVISIONS    OF   ANTENATAL    LIFE 


/ 


X 


DIVISIONS   OF   ANTENATAL   LIFE  9 

iu  the  embryonic  area  of  the  blastodermic  vesicle,  and  to  end  about 
the  close  of  the  sixth  week  of  intrauterine  life,  a  very  different  pro- 
cess is  going  on.  Tiiere  is  growth,  as  in  the  fcetal  period  ;  it  is  not, 
however,  simple  increase,  but  evolution  or  development  that  is  the 
striking  feature  of  the  life  of  the  embryo.  The  lines  along  which 
future  growth  is  to  take  place  are  nearly  all  fixed  during  the  embryonic 
period ;  the  outstanding  phenomenon  is  the  putting  up  of  the  scaflbld- 
ing  of  the  future  body ;  the  vitality  of  the  period  shows  itself  in 
organ  formation  or  organogenesis.  As  in  the  history  of  the  rise  of  a 
great  modern  city,  there  is  record  of  a  stage  in  which  the  mam  avenues 
of  traffic  are  sketched  out,  and  natural  olistacles  overcome  or  utilised,  to 
be  followed  by  a  period  during  which  growth  goes  on  along  the  lines 
of  the  plan ;  so  in  the  story  of  antenatal  life  there  is  the  embrj-onic 
period,  in  which  the  cellular  elements  are  arraiiged  in  groups  to  form 
organs,  to  be  followed  by  the  ftetal,  iu  which  these  organs  simply 
increase  in  size,  and  by  their  functional  activity  (in  some  instances) 
lead  to  the  growth  of  the  whole  organism.  This  embryonic  epoch  has 
a  duration  of  about  five  weeks,  or,  if  the  neofcetal  period  be  included, 
of  about  seven  weeks.  The  neofivial  is  a  sort  of  transition  time  during 
which  the  placental  circulation  and  economy  are  being  fully 
established ;  in  the  scheme  it  has  had  two  interspaces  (two  weeks) 
allotted  to  it.  Embryonic  life,  therefore,  like  foetal  life,  ends  with  a 
transition  time  or  period  of  adaptation  to  new  conditions ;  in  the  one 
case,  to  the  changes  consequent  upon  the  organism  l:)econiing  a 
placentally  nomished  one,  and  in  the  other  to  the  much  more 
radical  clianges  which  atmospheric  respiration  and  gastric  digestion 
entail. 

Tiie  earliest  period  of  antenatal  life  is  the  germinal,  and  only  a 
small  part  of  it,  at  its  close,  comes  into  the  epoch  of  intrauterine 
existence.  It  has  a  long,  a  very  long  primary  dual  period,  during 
which  a  semi-independent  life  of  a  cellular  kind  is  going  on  in  the 
male  and  female  reproductive  cells,  the  ovum  and  the  spermatozoon. 
In  the  scheme  a  dividing  line  indicates  this  primary  dual  character  of 
early  germinal  life.  The  close  of  the  dual  period  is  marked  in  the 
case  of  the  ovum  by  the  phase  of  maturation,  and  in  that  of  the  sperm 
by  the  little  known  but  probablj'  analogous  phenomena  of  spermato- 
genesis. Then  follows  the  anteconceptional  period,  during  which  there 
is  dehiscence  of  the  ovisac  in  the  female  with  passage  of  the  ovum 
along  the  Fallopian  tube  towards  the  uterus,  and  the  spermatozoa  are 
deposited  in  the  vagina ;  insemination  ends  this  and  begins  the  next 
period  (intraconceptional),  in  which  it  may  be  said  that  ovular  and 
sperminal  life  run  together  iu  impregnation.  Inasmuch  as  it  is  known 
that  in.semination  and  impregnation  are  not  of  necessity  simultaneous, 
I  have  thought  it  well  to  leave  half  an  interspace  (half  a  week)  in  the 
scheme  for  this  e\'ent.  The  rest  of  ger-minal  life  is  the  unifieil  post- 
conceptional  period,  during  which  the  morula  mass  and  the  blasto- 
dermic vesicle  are  forming,  and  the  first  traces  of  the  embryo 
appearing  in  the  embryonic  area.  In  the  scheme,  therefore,  the 
dividing  line  is  absent  in  the  postconceptional  period,  to  signify  its 
unified  character.     Germinal  life  may  be  said  to  pass  into  embryonic 


10  ANTKNATAI.    I'ATHOLOdV   AM)    IIYCUENK 

about  the  end  of  tlie  first  week  of    iiiliauteiiiie  existence,  a   fact 
marked  by  a  thick  black  Hne  in  the  chart. 

Thus  it  is  seen  that  antenatiil  Ufe  can  be  marked  olT  into  three 
sub(hvisions — ftotal,  embryonic,  and  germinal — of  wliich  two  only  (the 
fcctal  and  the  embryonic)  fall  entirely  witiiin  the  i>eri(id  of  intra- 
uterine existence,  while  one  (the  germinal)  stretches  back  in  its 
beginnings  into  the  cellular  life  of  the  jiarents  of  the  individual.  It 
will  become  evident,  as  the  study  of  Antenatal  Pathology  is  jau'sued, 
that  each  of  these  three  periods  is  liable  to  morbid  changes  which  are 
in  a  sense  jiecnliar  to  itself,  that  there  is  in  fact  a  fo'tal,  an  endjryonic, 
and  a  germinal  pathology;  but  before  this  matter  can  be  more  fully 
considered,  it  is  necessary  to  note  a  somewhat  important  modification 
which  must  be  made  in  such  a  scheme  of  antenatal  life  as  that  which 
has  been  described,  if  it  is  to  represent  what  actually  occurs. 

Scheme  of  Antenatal  Life. 

The  second  schedule  (Fig.  2)  gives  what  may  be  called  the 
corrected  scheme  of  antenatal  life.  It  will  probably  have  already 
struck  the  reader  that  the  division  of  antenatal  existence  by  hard-and- 
fast  lines  into  germinal,  embryonic,  and  fcetal  periods  is  not  free 
from  error.  It  is  quite  evident,  for  instance,  that  all  the  setting  up 
of  scallbldings  is  not  ended  at  the  end  of  the  sixth  week,  nor  yet 
indeed  at  the  end  of  the  thirteenth  ;  all  organogenesis  does  not  take 
place  in  the  embryonic  period,  some  of  it  is  still  going  on  in  the 
fietal.  One  part  of  the  organism  may  be  in  the  embryonic  stage 
while  the  others  are  in  the  foetal  phase.  In  order  to  represent  this 
fact  graphically,  I  have  carried  a  projection  of  embryonic  life  up 
through  the  neofa>tal,  fa'tal,  and  neonatal  periods  into  the  postnatal. 
The  skeleton  and  the  limbs  are  good  examples  of  parts  of  the  body 
whose  end)ryology,  so  to  speak,  does  not  end  with  the  endn-yonic 
epoch ;  the  uterus  and  teeth  are  instances  of  the  projection  of  the 
endjryonic  still  further  onwards,  i.e.  into  postnatal  life,  rrobably 
no  two  parts  of  the  developing  organism  pass  out  of  the  end)ryonic 
into  the  fojtal  condition  at  just  the  same  time.  To  revert  to  the 
comparison  I  have  already  instituted,  the  progress  of  the  growth  of  a 
city  is  not  equal  throughout ;  one  part,  e.g.  the  suburbs,  may  be  little 
more  than  planned  when  another,  c.ff.  the  centre,  is  already  built ;  so 
in  the  body,  the  evolution  of  the  limbs  is  slower  than  the  develop- 
ment of  tlic  head  and  trunk.  Again,  the  gernnnal  period  does  not 
alu-uptly  stop  at  the  end  of  the  first  week  of  pregnancy  :  the  character 
of  abundant  luxurious  cell  formation  which  so  specially  belongs  to  it 
is  projected  through  the  embryonic  and  foetal  periods,  and  is  seen  in 
postnatal  life  normally  in  one  organ,  the  reju'oductive  gland,  testicle  or 
ovary.  This  is  indicated  in  the  scheme,  which  also  rejiresents  in  a 
majihie  form  tlie  continuitv  of  (he  germ  jilasm  and  of  germinal 
life. 


DIVISIONS   OF   ANTENATAL   LIFE 


11 


FIG.    2. 
SCHEME   OF   ANTENATAL   LIFE. 


..NEONATAL   PERIOD. 


.RETAL  PERIOD.. 


..NEOFCETAL  PERIOD 


■  EMBRYONIC  PERIOD  - 


FCETAL  PERIOD 


-  EMBRYONIC   PERIOD  - 


(a)  Ovular  lite. 


Sptnottagtatsia. 
W  5periBln«l  llle. 


N 


12  ANTKNATAI.    I'All  l()I,( )( l^'    AND    I1V(;1EN]-: 

Subdivisions  of  Antenatal  Pathology. 

-lust  as  ill  postnatal  life  there  is  an  age  incidence  in  disease,  so  that 
the  maladies  of  the  infant,  tiie  adult,  and  tiie  aged  differ  from  each 
other  in  certiiin  details,  so  in  antenatal  life  morbid  processes  take  on 
different  characters,  according  as  they  occur  in  the  fo'tal,  in  the 
embryonic,  or  in  the  germinal  period.  There  are  three  main  sub- 
divisions of  Antenatal  Pathology  corresponding  to  tlie  three  main 
subdivisions  of  antenatal  jjhysiological  life.  There  \ii  fatal  patliology, 
which  is  concernetl  with  tlie  diseases  of  tlie  fo'tus ;  and  the  diseases 
of  the  foetus  are  in  great  measure  the  diseases  of  tlie  child  or  adult, 
modified  by  the  peculiarities  of  the  intrauterine  surroundings  and 
the  fu'tal  economy.  There  is  cmhryonic  pathology,  or,  as  it  is  more 
commonly  called.  Teratology,  which  deals  with  the  monsti'osities  of 
the  embryo,  for  there  is  good  reason  to  believe  that  morbid  agencies 
acting  on  the  embryo  produce  not  diseases  but  malformations  and 
monstrosities.  "When  the  malformed  embryo  becomes  a  fo'tus,  it 
carries  its  malformation  with  it  into  the  hctal  period,  and  is  born 
with  it  at  the  full  term  of  antenatal  life ;  but  the  malformation  is  not, 
as  has  sometimes  been  supposed,  the  product  of  late  but  of  early 
intrauterine  pathology.  A  third  part  of  antenatal  pathology  is 
concerned  with  the  action  of  morbid  causes  upon  the  organism  in  the 
germinal  period,  and  with  the  results  produced  thereby.  This  may 
be  termed /;*'rj;(  nia/ pathology.  It  includes  the  consideration  of  the 
morbid  processes  which  occur  in  the  ovum  at  and  immediately  after 
impregnation,  and  also  of  those  that  affect  the  re])roductive  cells 
(sperm  as  well  as  germ)  before  fertilisation :  and  it  has  probably  to  do 
with  double  monstrosities  (or  diploteratology),  hydatid  moles,  included 
foetuses,  blastoderms  elliptically  deformed  and  without  embryos,  and 
the  like.  Here  must  also  be  considered  the  very  springs  of  life  with 
their  jealously  guarded  secrets  and  the  hidden  mysteries  of  heredity. 
Roughly  speaking,  antenatal  pathology  may  lie  regarded  as  embracing 
the  study  of  congenital  diseases,  of  monstrosities,  and  of  niorliid 
predispositions  to  disease  or  deformity.  This  subdivision  of  Antenatal 
Pathohigy  is  not  fanciful  but  real,  more  real  certainly  than  the 
separation  of  postnatal  diseases  into  those  of  old  age,  adult  life,  and 
childhood.  Further,  just  as  in  antenatal  life  the  three  periods  cannot 
be  sharply  marked  oft'  from  one  another,  so  the  three  divisions  of 
Antenatal  Pathology  cannot  be  clearly  delimited, but  show  a  projection 
one  into  another:  but  of  this  full  details  will  be  forthcoming  in  later 
cha])ters  of  tliis  work. 

Increased   Interest  in  Antenatal  Pathology. 

Of  late  years  there  have  been  several  signs  of  an  increasing 
interest  in  Antenatal  I'athology.  A  literature  has  grown  u]>  around 
morbid  liereility.  and  there  has  been  much  written  on  the  vcxi'd 
question  of  the  possiljility  of  acquired  characters  becoming  hereditai-y. 
In  the  medical  journals  the  number  of  articles  devoted  to  subjects 
of  antenatal  interest  has  greatly  increased,  and  this  has  been  specially 


i  l^'^'(VERSiTy  j 

INTEREST   IN    ANTENATAL   PATHO'£6(flK)RNiJ^l  3 

noticeable  in  the  journals  of  France,  Italy,  and  the  United  States. 
Some  periodicals  1  now  publish  occasional  periscopes  of  both 
Teratology  and  Antenatal  Pathology,  and  the  subject  bulks  largely 
in  the  yearly  epitomes  of  scientific  and  medical  investigation  and 
progress.  In  Edinburgh  there  is  now  (1900)  a  University  Lecture- 
ship on  Antenatal  Pathology,  and  lectures  on  the  subject  have  also 
been  given  (1899)  in  connection  with  the  ]\Iedical  Graduates'  College 
and  Polyclinic  in  London ;  and  some  years  ago  a  quarterly  journal 
entirely  devoted  to  Antenatal  Pathology  appeared  and  was  continued 
for  two  years,  living  long  enough  to  demonstrate  that  there  was  at 
any  rate  no  lack  of  material  wherewith  to  till  the  pages  of  such  a 
periodical.  In  a  less  evident  but  more  permanent  manner  the  ante- 
natal factor  has  been  making  its  presence  felt  in  many  of  the  branches 
of  medical  study ;  and  in  the  diseases  of  the  nervous  system,  for 
instance,  what  may  be  called  the  teratological  theory  of  degeneration 
has  of  late  excited  miich  interest. 

The  causes  of  this  increased  attention  to  matters  of  antenatal 
interest  are  many  and  various  ;  they  are  economic,  scientific,  senti- 
mental, practical,  and  political.  In  the  first  place,  to  take  an 
eminently  practical  cause,  there  has  been  an  increase  in  the  value 
set  upon  fcetal  life,  due  to  the  fact  that  in  certain  countries  the 
population  is  no  longer  going  up  by  leaps  and  bounds.  A  falling 
birth-rate  and  an  increasing  interest  in  Antenatal  Pathology  are 
matters  which  have  come  together,  not  quite  fortuitously,  in  the 
dawn  of  a  new  centurj'.  When  the  birth-rate  begins  to  go  down, 
the  value,  economic  as  well  as  sentimental,  of  the  unborn  infant 
begins  to  go  up.  When  few  infants  are  being  born,  it  becomes 
important  that  they  shall  come  living  to  the  light  at  the  full  term, 
well-formed  and  healthily  cajaable  of  independent  extrauterine 
existence;  and  these  desirable  conditions  are  evidently  largely  the 
result  of  normal  antenatal  circumstances.  When  parents  are  un- 
natural enough  to  determine  voluntarily  to  limit  their  progeny  to 
two  or  three,  it  is  natural  enough  that  they  should  desire  that  the 
limited  family  be  a  healthy  family.  "  The  infants  are  to  be  few," 
they  say,  "  let  them  then  be  fine."  An  unworthy  motive,  doubtless, 
but  one  that  has  drawn  the  attention  of  a  nation  to  puericulture  ! 
Paris  has  now  hospitals  where  women  can  rest  during  the  last  two 
months  of  pregnancy,  for  it  has  been  found  that  the  women  who  have 
to  do  hard  manual  labour  up  to  the  term  of  gestation  do  not  have 
such  healthy  or  such  heavy  infants  as  those  who  are  able  to  rest. 
Further  evidence  of  the  appreciation  in  the  value  of  fcetal  life  which 
has  of  late  taken  place,  is  seen  in  the  crusade  amongst  obstetricians 
against  what  is  called  therapeutic  fa^ticide ;  that  is  to  say,  against  the 
operations  carried  out  on  behalf  of  the  mother  which  condemn  the 
foetus  to  certain  or  to  probable  death.  Among  such  fceticidal  operations 
are  reckoned  craniotomy  (and  other  embryulcic  procedures)  upon  the 
living  fretus,  prolonged  and  difficult  forceps  and  version  cases  in 
contracted  pelves,  and  artificial  premature  labour.  Into  the  questions 
which  this  crusade  has   brought  to  the  front  it  is  not  my  purpose 

'  Archives  of  Pediatrics  ;  St.  Zvuis  Medical  and  Sunjical  Jowrnal,  etc. 


14  ANTKNA'I'AI,    1' ATIIOLOCY    AM)    HY(;iKNK 

here  to  enter :  tluit  there  is  a  crusade  is  evidence  that  the  life  of  the 
fd^tuH  is  iiKirc  lii^'hly  valued.  (Ireatercare  is  now  taken  to  save  alive 
prematurely  liorn  infants,  and  Maternity  Hospitals  are  in  many  cases 
jirovided  not  only  with  rouvcuscs  but  even  with  specialised  wet- 
nurses;  for  witli  a  falling  liirth-rate  even  the  six-months  fo-tus  has 
a  certain,  if  undetermined,  value.  All  these  attempts  to  conserve 
f(etal  life  have  brought  in  their  train  a  closer  inquiry  into  foetal 
physiology,  and  more  direct  investigation  of  the  causes  of  fojtal 
disease  and  deatli. 

In  the  second  place,  the  increasing  burden,  financial  and  otherwise, 
upon  tlie  State,  due  to  the  presence  in  the  community  of  the  "unfit," 
has  done  something  to  direct  attention  more  particularly  to  Antenatal 
Pathology  and  Antenatal  Therapeutics.  There  can  be  no  doubt  that 
many  of  tlie  unfit  are  congeuitally  unfit:  they  come  into  the  world 
epile])tics  or  criminals  or  idiots  or  paralytics,  from  their  mother's 
womb.  Manifestly  it  would  be  much  better  for  the  public  lieallh  and 
less  expensive  for  the  State,  if  the  jinijection  of  the  congcnitally  unfit 
into  societ)'  could  be  prevented.  I'reventive  medicine  will  not  have 
attained  to  its  highest  developments  until  it  has  solved  the  problem 
of  antenatal  prevention.  I'revention  in  order  to  be  truly  prevention 
must  be  antenatal.  Within  recent  years  the  attempt  has  been  made, 
by  means  of  the  legal  restriction  of  the  marriage  of  the  unfit,  to  ])revent 
the  procreation  of  the  unfit.  The  attempt  has  had  n<i  conspicuous 
success,  a  result  due  in  part  to  'the  absence  of  accurate  knowledge 
regarding  the  laws  that  determine  antenatal  health  and  disease,  so 
that  it  was  impossible  to  predict  tliat  the  children  of  the  unfit  would 
of  necessity  be  equally  or  in  the  same  way  unfit.  Its  failure  has 
at  least  stimulated  investigation  into  the  problems  of  Antenatal 
Pathology.  In  some  cases,  no  doubt,  the  unfitness  of  the  offspring 
is  the  result  of  intranatal  rather  than  antenatal  causes,  as  is  seen  in 
some  of  the  obstetrical  or  birtli  paralyses;  but  this  fact  increases 
rather  than  diminishes  our  interest  in  the  truly  antenatal  cases,  for 
the  intranatally  produced  morbid  conditions  are  generally  more 
ameualile  to  treatment. 

In  the  third  place,  advances  in  other,  but  cognate,  branches  of 
medical  and  biological  science  have  directed  attention  to  Antenatal 
Pathology.  There  can  be  no  doubt  that  tlie  Darwinian  hy))othesis  of 
evolution,  with  all  the  supporting  or  opposing  theories  to  wiiicli  it  has 
given  rise,  has,  by  exciting  interest  in  lieredity,  turned  tlie  attention  of 
many  scientists  to  the  problems  of  morliid  heredity,  predisjiosition.  and 
imnninity.  Advances  in  embryology  and  in  fu'tal  physiology  have 
also  done  much  to  render  possible  the  pronudgation  of  correct  views 
on  foetal  and  embryonic  pathology.  At  first  tlie  discover}'  of  the 
niicrobic  origin  of  many  diseases,  such  as  tuberculosis,  tended  to 
divert  attention  from  the  older  views  of  heredity ;  but  now  the 
interest  is  sliifting  again,  and  discu.ssion  is  rife  regarding,  not  so  much 
the  germs  of  disease  as  the  antcnatally  ]ire]iared  soil  into  wliich  these 
germs  may  fall.  After  many  j-ears,  in  which  the  seed  lias  monopolised 
attention,  a  time  has  arrived  in  which  our  thoughts  are  directed  to 
the  soil.     Even  apart  from  this  aspect  of  the  subject,  the  scientific 


INTEREST   IX    ANTENATAL    PATHOLOGY  15 

interest  and  attraction  of  many  of  tlie  problems  of  Antenatal  I'atlio- 
logy,  not  excluding  the  causation  of  monstrosities,  are  N'ery  real. 

In  the  fourth  place,  and  finally,  it  is  to  be  hoped  that  the  humane 
desire  to  carry  to  the  infant  yet  unborn  some  of  the  Ijenefits  of 
modern  medicine  and  hygiene  has  been  and  is  instrumental  in 
attracting  many  members  of  the  medical  profession  to  the  study  of 
antenatal  aflairs.  In  a  retrospect  of  the  medicine  of  the  nineteenth 
century,  two  lines  of  progress  stand  very  prominently  out :  that  which 
has  led  to  the  development  of  gynaecology  and  so  benefited  many 
millions  of  suffering  women,  and  that  which  has  produced  pediatrics 
and  the  pediatrist,  and  so  saved  much  child  life  and  ameliorated 
much  child  suffering.  jMay  it  not  be  that  the  twentieth  century 
will  witness,  among  other  good  things,  a  wonderful  extension  and 
development  of  beneficent  Antenatal  Therapeutics. 


CHAPTER    11 

The  Relation  of  Aiiteniital  Patlinlugy  to  the  other  I'lauches  of  Study  ;  Scheme 
of  Rehitioiisliips ;  Kehition  to  General  Pathology;  Helatiou  to  the  Bio- 
logical Scienie- — Anatomy,  Embryology,  Physiology,  Botany,  and  Zoology  ; 
Relation  to  the  Medical  Sciences — Obstetrics,  Public  Health,  Pediatrics, 
Medicine,  Psychology,  Dermatology,  Surgery,  Orthopedics,  and  Medical 
Jurispruilence  ;  Relation  to  Gynecology  and  Neonatal  Pathology. 

Antenatal  Pathology  does  not  staud  in  splendid  isolation  among 
the  other  departments  of  medical  and  biological  science.  If  there 
be  any  degree  of  aloofness,  it  is  rather  exhibited  by  the  other 
departments.  There  is  indeed  a  very  evident  and  constant  antenatal 
factor  in  most  of  the  branches  of  medical  and  biological  study ; 
congenital  diseases  and  deformities  and  morbid  predispositions  are 
found,  if  looked  for,  playing  their  part  and  producing  their  etlect 
in  many  ways  in  the  various  subdivisions  of  the  healing  art.  Why, 
then,  bring  together  into  one  subject  what  is  present  in  all  the 
other  suljjects?  Why  make  a  new  subject,  when  the  subdivisimis 
of  medicine  and  surgery  are  already  so  numerous  ?  For  the  reason, 
that  there  is  much  to  be  learned  from  such  a  centralisation  of 
knowledge  regarding  antenatal  atl'airs,  much  that  cannot  be  learned 
ill  any  other  way.  Facts  about  antenatal  conditions  in  Medicine, 
or  Surgery,  or  Dermatology,  or  Psychology,  standing  l)y  themselves, 
have  not  been  of  use  in  throwing  light  upon  each  other,  and  have 
not  had  enough  light  in  themselves  to  make  their  nature  and  origin 
plain.  The  gathering  together  of  all  these  scattered  facts  into  one 
subject,  Antenatal  Pathology,  and  the  comparing  of  them  there,  one 
with  another,  have  not  only  added  to  our  knowledge  of  tlie  whole 
subject,  but  have  again  increased  our  acquaintance  witii  each  part 
of  it.  The  alternate  assembling  together  and  ditl'using  of  information 
liave  increased  the  sum  of  knowledge.  In  this  respect  Antenatal 
Pathology  may  be  compared  to  a  river  like  the  Nile,  which  by  its 
tributaries,  White,  Blue,  ])ahr-el-Gebel,  and  the  otiiers,  draws  supplies 
from  various  soils  and  diflerent  geological  formations,  sweeps  them 
down  in  one  broad  stream,  to  lie  again  broken  ujt  and  redistributed 
as  a  fructifying  Hood  dver  all  the  Delta  lands.  It  is  for  the  good 
of  each  deparlnient  of  Jledicine  that  the  contribution  which  it  is 
able  to  make  to  Antenatal  Pathology  be  brought  alongside  the  con- 
tributions from  the  other  departments,  and  contrasted  and  compared 
with  them.  Congenital  conditions  of  the  eye,  or  tlie  ear,  or  the 
skin,  all  help  in  making  it  possilde  to  understand  the  general  laws 


RELATIOXSHIPS   OF   AXTP:NATAL    I'ATHOLOCiY         17 

which  govern  Antenatal  Pathology,  and  the  understaniling  of  these 
laws  again  makes  it  far  easier  to  understand  the  special  working 
of  them  in  each  individual  snljject.  In  this  way  centralisation,  with 
a  view  to  further  decentralisation,  and  again  to  recentralisation, 
makes  progress  possible,  and  helps  to  read  many  a  hard  riddle. 

But  Antenatal  Pathology  is  not  equally  related  to  all  the 
departments  of  Medicine  and  Biology ;  it  is  more  immediately  bound 
up  with  some  than  with  others.  Its  connections,  near  and  remote, 
are  represented  in  the  accompanying  scheme  (Fig.  3). 

With  General  Pathology  the  subject  of  Antenatal  Pathology  lias 
a  very  intimate  relation,  for  it  is  truly  a  part  of  it,  although  it  has 
received  but  scant  recognition  in  many  of  the  text-books.  In  the 
same  sense  that  the  pathology  of  the  skin  or  of  the  female  organs  of 
generation  belongs  to  Pathology,  the  study  of  the  morbid  changes 
of  the  foetus  anil  embryo  belongs  to  Pathology ;  l_)ut  in  the  case  of 
the  latter  the  union  is  or  ought  to  be  an  even  closer  one.  Nearly 
every  pathological  problem  has  an  antenatal  aspect,  and  it  may  soon 
lie  found  necessary  to  revise  the  current  views  on  Pathology  in  the 
light  of  recent  investigations  into  the  morliid  processes  of  embryonic 
and  fretal  life.  It  seems  more  than  likely  that  the  whole  question 
of  tumours  and  their  origin  will  require  to  Ije  approached  from  this 
side :  while,  in  such  matters  as  immunity  and  predisposition,  the 
antenatal  element  must  always  play  an  important  part.  The  rela- 
tion of  Antenatal,  Xeonatal,  and  General  Pathology  to  one  another 
is  represented  in  the  scheme  by  concentric  circles.  Antenatal  Path- 
ology is  also  related  to  the  biological  sciences.  With  Anatomy  it 
has  a  very  real  connection  through  Embryology,  for  the  normal 
and  the  abnormal  throw  light  upon  each  other ;  with  Physiology 
there  is  a  bond  in  Fu?tal  Physiology,  a  subject  as  yet  comparatively 
luiworked,  but  certain  to  Ije  fertile  in  results,  and  through  it 
with  Chemistry.  It  is  chietly  through  the  existence  of  a  Teratology 
of  Plants  that  the  subject  comes  into  relation  with  Botany ;  possibly 
the  botanist  and  the  pathologist  have  not  proved  so  mutually  pro- 
fitable as  they  might  have  done ;  certainly  Vegetable  Teratology, 
dealing  as  it  does  with  comparatively  simple  structures,  may  be 
exjiected  to  elucidate  the  problems  of  malformations  in  the  animal 
world.  With  Zoology  there  exists  a  firm  bon<l  (if  uniiin  in  Ciim- 
parative  Teratology  (the  study  of  fcetal  diseases  in  animals,  or  Com- 
parative Foetal  Pathology,  has  scarcely  yet  made  a  beginning);  in 
fact  one  can  hardly  separate  Human  and  Comparative  Teratology 
even  in  thought.  Over  and  over  again  Comparative  Embryology 
has  proved  of  great  value  in  clearing  up  moot  points  in  Teratology, 
and  conversely  Teratology  has  helped  in  the  study  of  Zoology.  It 
may  be  noted  here,  in  passing,  that  of  late  the  invertelirata  have 
been  much  employed  in  experimental  work  in  Teratology  (Terato- 
genesis).  In  the  scheme  the  relations  of  Antenatal  Pathology  to 
the  biological  sciences  ai-e  represented  by  ailjacent  circles  with  con- 
necting lines ;  the  arrangement  speaks  for  itself. 

But  Antenatal  Pathology  is  related  not  only  to  the  liiological 
but  also  to  the  purely  medical  sciences,  and   its   relations   in  this 


I 
I 

I 


kf:lationships  of  antenatal  pathology       10 

direction  are  indicated  diagranimatically  likewise.  From  time  imme- 
morial the  obstetrician  has  looked  upon  the  diseased  or  monstrous 
fietus  as  peculiarly  in  his  field  of  study ;  although,  doubtless,  he  has 
too  often  neglected  to  study  it,  and  simply  recorded,  or  (still 
worse)  only  bottled  it.  He  is  the  first  in  order  of  time  to  see  speci- 
mens of  Antenatal  Pathology,  and  he  can  enjoy  the  great  privilege 
(of  which,  imfortunately,  he  does  not  often  avail  himself)  of  exam- 
inhig  the  parts  of  his  intrauterine  environment  which  the  new-born 
infant  brings  with  him  into  the  world,  namely,  the  placenta,  mem- 
branes, and  cord.  Apart  from  the  unworthy  tendency  to  hoard, 
without  dissecting,  the  specimens  which  come  into  his  possession, 
the  obstetrician  has  done  much  to  forward  the  understanding  of 
antenatal  problems.  It  must  not  be  forgotten,  also,  that  he  knows 
the  clinical  details  of  the  ease,  which  are  often  conspicuous  by  their 
absence  in  reports  from  the  pathological  laboratory ;  and  that  by 
him  the  way  must  of  necessity  be  opened  up  for  antenatal  diagnosis. 
The  connection  between  Antenatal  Pathology  and  Obstetrics  is  one 
which  affects  not  only  the  fcptus,  but  also  the  motlier ;  for  in  the 
maternal  organisms  may  be  found  the  results  of  morbid  processes 
which  occurred  before  birth,  and  which  are  now  interfering  with 
the  birth  of  the  ne.\t  generation.  Among  them  may  be  mentioned 
the  congenital  deformities  of  the  pelvis,  due  to  mal-development  of 
the  sacrum,  to  premature  ossification  of  the  sacro-iliac  synchondroses, 
to  dislocation  of  the  hip,  and  to  the  presence  of  antenatal  exostoses 
growing  from  the  margin  of  the  pelvic  inlet :  labours  complicated 
by  these  anomalies  are  necessarily  delayed  and  thus  rendered  danger- 
ous. Uterine  malformations,  also,  such  as  the  didelphic  and  sub- 
septate  or  septate  condition,  do  not  exist  in  parturition  without 
disturbance  of  its  mechanism.  In  these  ways  the  antenatal  patho- 
logical history  of  the  mother  projects  its  infiuence  into  her  later 
postnatal  life. 

Through  Obstetrics,  Antenatal  Pathology  finds  a  connecting  link 
with  Puljlie  Health,  for  it  is  obvious  that  if  the  community  is  to 
be  strong  and  well  alile  to  resist  epidemics,  it  must  be  constantly 
reinforced  by  the  healthy  oflspring  of  normal  pregnancies.  It  is 
doubtful  if  this,  the  highest  development  of  preventive  medicine, 
has  yet  received  the  attention  that  it  certainly  deserves.  At  any 
rate,  the  tremendously  high  mortality  among  infants  of  less  than  a 
year  old  which  prevails,  goes  to  show  that  many  children  are  Isrouglit 
into  the  world  very  little  fit  to  cope  with  the  environmental  trials 
tliat  there  await  them.  Some  progress  has  been  made  in  the  hygiene 
of  antenatal  life,  and  it  is  recognised  that  certain  trades  and  occupa- 
tions are  injurious  to  pregnant  women,  not  solely  because  they 
interfere  witli  the  maternal  health,  but  because  they  have  an  evil 
influence  upon  the  infant  unborn.  There  is,  however,  much  still  to 
be  done  in  this  Ijranch  of  Public  Healtli. 

Obstetrics  is  linked  on  to  Medicine  by  means  of  Pediatrics,  and 
in  this  way  a  connection  is  established  between  Antenatal  Pathology 
and  Medicine,  for  the  study  of  the  diseases  of  the  child  serves  to 
explain  both  the  diseases  of  the  adult  and  the  maladies  of  the  foetus, 


20  ANTF.NATAI,    I'A'lHOI.CXiY   AND    HYCUKNK 

;ui(l  1k'1|)s  also  to  I'ccdiicili'  a]i]iar('iit  <liireiuiR-e.s  lictwuLMi  the  jiatho- 
liit;ical  jirocesses  of  ailvaiicoil  jiostiiatal  lifi'  ami  of  early  antenatal 
life.  Bill  Meilieine  is  directly  unitetl  with  Antenatal  ralimlogy  in 
several  ways,  a])art  from  the  connection  tlirougli  Olistetries.  One 
of  tliese  ways  is  I'syeholoiiy  and  the  Diseases  of  the  Xervons  System  ; 
in  fact,  it  is  specially  in  the  department  of  the  maladies  of  tlie  liraiii 
and  cord  that  the  antenatal  factor  in  medicine  has  lieen  recognised. 
Without  referring  to  conditions  such  as  idiocy  and  deaf-niutisni,  the 
congenital  nature  of  which  is  midoubted,  instances  nmy  he  cited  in 
the  so-called  obstetrical  paralyses,  Thomsen's  disease,  epilepsy.  Fried- 
reich's disease,  and  syringomyelia.  Dana,  in  his  contribution  to  the 
pathology  of  hereditary  chorea  {Journ.  Ncrv.  and  Mcnt.  iJi^.,  xxii. 
565,  1895),  comes  to  the  conclusion  that  "  the  disease  belongs  to 
Teratology";  and  Fere  has  advanced  a  teratological  theory  to 
explain  the  neuropathic  family  and  its  relations  with  heredity, 
morbid  predisposition,  and  degeneration.  In  other  departments  of 
medicine  the  presence  of  the  antenatal  factor  can  also  be  noted  if 
looked  for.  In  Dermatology,  for  instance,  it  is  present,  fur  it  is 
admitted  that  many  skin  diseases,  even  if  not  actually  evident 
at  bii-th,  are  predisposed  to  antenatally.  To  name  only  a  few, 
there  are  the  various  forms  of  ichthyosis,  tylosis  pahme  et  plant  ;e, 
hypertrichosis,  hypotrichosis,  albinismus,  and  the  na:'vi.  C(ingenital 
heart  disease,  h;emophilia,  and  syphilis  are  conditions  which  pro- 
foundlj'  influence  the  whole  life  of  the  individual  who  is  unfortunate 
enough  to  l.)e  thus  luuidicajiped  antenatally;  and  recent  observations 
go  to  show  that  congenital  tuljerculosis  is  a  much  more  imjiortant 
factor  in  pathology  than  has  been  hitherto  supposed.  Chlnrosis 
also,  and  other  blood  disorders,  are  now  known  to  be  often  associated 
in  a  very  striking  way  with  antenatal  malformations. 

Little  requires  to  be  said  about  the  relation  in  which  Antenatal 
I'athology  stands  to  Surgery.  The  two  subjects  are  connected 
together  very  obviously  by  the  department  of  surgical  practice 
known  as  Orthopedics.  It  is  a  striking  fact  that  many  of  the 
most  recent  advances  in  surgery  have  been  made  in  the  rejiarative 
treatment  of  congenital  deformities  and  malformations,  sn  that  at 
the  present  time  Orthopedics  is  one  of  the  most  jirogressive  branches 
of  practice.  Hare-lip,  cleft  palate,  club-foot,  ectopia  vesica-,  irnjier- 
forate  anus,  phimosis,  congenital  dislocation  of  the  hip,  and  cervical 
tistuke  are  some  of  the  antenatal  morbid  states  that  are  constantly 
forcing  themselves  upon  the  notice  of  the  surgeon,  and  there  are 
many  more,  including  several  for  the  repair  of  which  the  operator 
has  yet  to  find  a  successful  method.  There  can  be  no  doubt,  also, 
that  the  more  the  causation  and  niode  of  production  of  deformities 
are  understood,  the  more  ratiimnl  will  their  treatment  become.  AVhat 
has  been  said  with  regard  to  Cieneral  Surgery  might  be  re]ieated  in 
reference  to  the  Special  Surgery  of  the  Eye,  Ear,  Throat,  and  Genitals, 
for  in  all  these  specialities  the  antenatal  factor  can  be  traced  in  the 
form  of  malformations  or  of  congenital  diseases. 

Even  ]\Iedical  Jurispnulence  or  Legal  ^ledicine  must  be  counted 
as  a  subject  containing  many  matters  ('.;/.  the  social  and  ]Hilitical 


RELATIONSHIPS   OF   AXTEXATAI,    PATHOLOGY         21 

rights  of  so-called  heniuiphrodites,  questions  of  identity,  and  of 
concealment  of  pregnancy,  etc.),  upon  which  Antenatal  Pathology 
can  throw  light. 

It  is  therefore  clear  that  Antenatal  Pathology  occupies  no  isolated 
position  among  the  other  subjects  of  study,  but  is  related,  in  some 
instances  closely,  with  them  all.  The  degrees  of  relationshij)  have 
been  diagrammatically  represented  in  the  scheme  (Fig.  3).  There 
is,  however,  a  somewhat  noteworthy  fact  about  these  relations  which 
is  not  brought  out  in  the  scheme ;  it  is  with  regard  to  the  time 
after  birth  when  the  antenatally  determined  morbid  state  may  make 
its  influence  felt.  In  some  cases,  as  in  the  diseases  of  the  new-born 
infant,  the  eft'ect  of  antenatal  states  is  practically  immediate ;  in 
other  instances,  as  in  the  pathology  of  the  female  genital  organs, 
the  antenatal  factor  is  during  many  years  inactive,  or  at  least  hidden 
in  its  action,  and  it  is  only  when  reproductive  life  begins  that 
malformations  or  congenital  diseases  of  the  uterus  and  its  annexa 
commence  to  show  themselves  in  disordered  function.  In  the  next 
chapter  the  antenatal  factor  in  Gynecology  will  be  taken  as  a  type 
of  the  postponed  action  of  states  determined  before  birth  upon  con- 
ditions existing  long  after  birth ;  the  following  three  chapters  will 
be  devoted  to  the  immediate  relation  of  Antenatal  to  Neonatal 
Pathology. 


CHAPTER   III 

The  Postponed  Effect  of  Antenatal  Pathology  :  the  Antenatal  Factor  in  Gynecology ; 
Traumatism,  Infection,  Antenatal  Conditions ;  the  Antenatal  Factor  in 
the  Morbid  Anatomy,  Symptomatology,  Etiology,  Diagnosis,  Prognosis, 
Therapeutics,  and  Juiisprudence  of  Gynecology. 

As  was  pointed  out  in  the  preceding  cliaiiter,  Antenatal  ratholog}- 
has  with  some  of  the  subjects  of  medical  practice  an  immeiliate 
relation,  and  with  otliers  what  may  lie  termed  a  remote  <ir  postponed 
connection.  It  is  on  account  of  the  postponed  rather  than  of  the 
immediate  action  of  the  antenatal  factor,  however,  that  the  attcntinn  of 
the  medical  profession  has  hitherto  lieen  drawn  to  the  consideration 
of  Antenatal  Patholooy.  The  reason  is  evident :  in  its  postponed 
action  the  science  is  dealing  with  the  morbid  states  of  adults,  or  at 
any  rate  of  children  and  youths,  while  in  its  immediate  eH'ects  the 
foetus  or  embryo,  or  at  most  the  new-born  infant  alone,  is  interested. 
The  postponed  action  of  the  antenatal  factor,  or,  as  it  may  be  called, 
the  projection  of  the  antenatal  into  the  after  life  of  the  individual, 
has,  at  least  at  first  sight,  the  greater  economic  importance,  inasmuch 
as  the  life  of  the  adult  or  child  is  of  more  value  than  the  life  of  the 
fcetus  or  new-born  infant.  Without  admitting  that  this  is  the  right 
view,  either  from  the  high  standpoint  of  science  and  morality  or  from 
the  more  prosaic  one  nf  practice,  it  will  be  convenient  iiere  to  con- 
sider this  postponed  action  of  Antenatal  Pathology.  I  select  tlie 
antenatal  factor  in  Gynecology  simply  because  it  will  serve  as  a  very 
clear  instance  of  the  element  of  ]iostponement  to  which  I  have  l)een 
referring. 

The  Antenatal  Factor  in   Gynecology. 

"While  it  is  generally  conceded  that  in  the  etiology  of  gynecological 
affections  there  are  two  factors  of  jiarann)unt  importance,  the  trau- 
matic and  the  infective  or  toxic,  it  is  probable  that  too  little  heed  lias 
been  given  to  a  third  factor,  the  antenatal.  Evident  traumatic  and 
infective  causes  hx\e  overshadowed  less  evident  predisposing  causes ;  mi 

etiological  factors  immediately  preceding  the  resulting  diseases  have  f: 

bulked  more  largely  in  the  mind  of  the  gynecologist  than  antenatal 
causes,  which  had  their  origin  years  ago  before  tlie  uterus  and  ovaiies 
awoke  to  functional  life.  Yet  sue!)  e.xist,  and  it  is  necessary  for  the 
full  iniderstanding  of  gynecological  jiroblems  that  attention  be  ]iaid 
to  the  antenatal  factor. 


ETIOLOGICAL   FACTORS    IX   (JYNECOLOGY  23 


Traumatism  and  Infection. 

Ill  cervical,  vaginal,  perineal,  and  vulvar  lacerations  every  one 
recognises  the  traumatic  factor.  Year  by  year  such  lacerations  liave 
diminished  in  frequency,  as  the  direct  result  of  improvements  in  the 
construction  of  obstetric  iiistrunients,  and  of  the  growth  of  correct 
opinions  as  to  their  use.  There  has  been  in  the  last  decade  a  note- 
worthy decrease  in  the  number  of  cases  calling  for  operation  for 
repair  of  vesico-vaginal  listuLe,  and  instances  of  grave  laceration  of  the 
perineum  are  not  so  common.  The  great  importance  of  the  role  of 
the  infective  factor  in  gynecological  etiology  is  now  well  established. 
Every  text-book  devoted  to  gynecology  and  every  medical  journal 
teems  with  allusions  to  the  part  played  by  sepsis,  gonorrhoea,  and 
tubercle  in  the  production  of  inflammatory  processes  in  the  uterus, 
its  annexa,  and  in  the  vagina,  vulva,  and  pelvic  cellular  and  peritoneal 
tissues.  Uterine  and  ovarian  displacements,  and  hypertrophic, 
atrophic,  and  httmorrhagic  changes  in  the  generative  organs,  must  in 
many  instances  Ije  ascribed  to  this  cause,  acting  either  alone  or  in 
conjunction  with  traumatism.  In  this  group  are  included  not  only 
the  morbid  states  due  to  the  action  of  micro-organisms,  such  as 
streptococci  and  gouococci,  but  also  those  caused  by  parasites  such  as 
echinococci  and  pediculi.  A  great  part  of  the  work  of  the  gyneco- 
logist of  the  present  day  consists  in  the  making  of  attempts,  sometimes 
by  medicinal  means  alone,  but  more  often  and  more  effectivelj*  by 
operative  procedures,  to  undo  the  results  of  acute  and  chronic  infective 
conditions  of  the  genital  organs.  Most  of  the  cases  which  he  is  con- 
stantly meeting  can  be  traced  in  their  origin  either  to  immediate 
infection  or  to  infection  following  after  traumatism.  Further,  even 
in  the  cases  in  which  operative  interference  is  required  for  non- 
infective  states,  such  as  ovarian  cystomata  and  uterine  neoplasms,  it  is 
still  infection,  septic  or  otherwise,  that  the  operator  most  dreads,  and 
it  is  against  infection  that  his  best  eflbrts  are  directed.  Xevertheless, 
while  all  this  is  perfectly  true,  no  gynecologist  can  be  long  in  active 
practice  without  perceiving  that  traumatism,  microbic  and  parasitic 
infection,  and  toxic  influences  do  not  serve  to  explain  all  the  morbid 
conditions  and  all  the  phenomena  connected  with  them,  which  he  is 
every  day  encountering  and  having  to  treat.  Ere  long  he  suspects 
the  existence  of  another  factor  :  this  is  the  antenatal. 

The  Antenatal  Factor. 

By  tlie  antenatal  factor  in  gynecology,  I  mean  something  more 
than  the  existence  of  gross  malformations  of  the  uterus,  with 
tlieir  etiects  upon  the  performance  of  the  functions  of  reproductive 
life.  These,  of  course,  are  included ;  but  I  mean,  also,  all  those 
abnormalities  in  structure,  predispositions  towards  certain  diseased 
processes,  and  inherited  functional  peculiarities,  which  there  is  good 
reason  to  believe  are  determined  antenatally,  and  which  have  often- 
times so  powerful  an  effect  upon  the  progress  of  gynecological  cases. 


24 


ANTKNA'lAI,    I'A  11  lOIXXiY    AND    1 1 'X  i  1 KN  K 


The  nccurrence  of  sucli  aiininalies  as  atresia  of  tlie  vaj,niia,  (loul)le 
utenus,  and  ilefeetive  formation  of  the  ovaries,  is  well  known  to  every 
gynecologist:  every  one  is  ahle  fairly  accurately  to  forecast  what  the 
jn-ohahle  result  of  this  or  thai  malformation  will  be.  P>nt  there  are 
otiicr  and  more  suljtle  ways  in  which  conditions  and  tendencies,  jiro- 
dueed  before  the  birth  of  the  individual,  project  themselves  into  her 
later  life  ;  these  are  not  so  generally  known,  at  least  theii  far-reaching 
eH'ects  are  not  so  fully  appreciated.  It  may  at  once  be  admitted  that 
it  i.s  not  possible  to  arrange  all  the  morbid  states  which  att'ect  tlie 
female  generative  organs  \nider  one  or  other  of  these  three  factors : 
an  etiological  classification  of  gynecological  comj)laints  is  not  so 
simple  a  matter.  It  is  not  practicable,  for  instance,  to  group  together 
all  the  diseases  of  the  uterus  that  are  due  to  infection,  and  then  all 
those  that  are  due  to  traumatism,  and  then  all  those  due  to  antenatal 

states,  in   a   linear   series.     It  would 

l)e  coming  more  nearly  to  tiie  truth 
if  the  three  factors  were  represented 
by  three  circles,  two  of  whicli  (the 
traumatic  and  the  infective)  liisccted 
one  another,  while  the  third,  the  ante- 
natal, touched  the  circumferences  of 
the  first  and  second,  thus  : 

I  do  not  forget  that  other  causal 
factors  than  the  three  just  named 
liave  been  recognised  in  gynecology; 
they  act  chiefly  through  the  nervous 
system,  and  consist  chiefly  in  un- 
hygienic methods  of  education,  in 
delayed  marriage,  in  prevented  con- 
Yk;    j  ception,   and    in    irrational    modes   of 

dress.  These  errors  practised  by  one 
generation  of  women  Ijecome  the  antenatal  causes  of  defective  develop- 
ment of  the  whole  system,  and  especially  of  the  re])roductive  organs 
of  tlie  individuals  of  the  next  feneration. 


The  Antenatal  Factor  in  the  Morbid  Anatomy  of  Gynecology. 

The  antenatal  factor  is  very  evident  in  the  morbid  anatomy  of 
gynecology.  All  the  major  malformations  of  the  female  generative 
organs  and  nearly  all  the  minor  ones  are  truly  antenatal  in  origin. 
Trifling  exceptions  are  found  in  the  uterus  pubescens,in  atresia  vulvre 
superficialis,  arising  from  adhesive  vulvitis  in  infancy,  and  in  some 
hypertrophic  conditions  of  the  labia  and  clitoris.  The  various  types 
of  doulile  uterus  (didelphic,  liicornate,  septate),  the  uterus  unicornis, 
the  uterus  rudimentarius,  the  uterus  fa>talis,  the  minor  uterine  mal- 
formations (incudiformis,  parvicollis,  etc.),  and  absence  of  the  uterus; 
absence  and  atresia  of  the  vagina,  double  vagina,  unilateral  vagina, 
and  stenosis  vagina; ;  vulvar  and  hymeneal  anomalies  ;  absence  and 
rudimentary  development  of  the  ovary,  accessory  ovaries,  accessory 
tubal  diverticula  and  ostia,  and  rudimentarv  tubes  :  and  the  various 


ANTENATAL  FACTOR  IN  GYNFXOLOGICAL  PATHOI.OCiV      2.") 

fmius  of  pseuilo-heniiapbruilitisiu  ; — these  are  some  of  the  admilteilly 
antenatal  niorhid  states  of  the  female  genitals.  They  are  dealt  witli 
in  greater  or  less  detail  in  all  the  text-books  of  gynecology  (6,  lo,  14). 
It  may  be  noted  in  pa.ssing  that  all  these  anomalies  are  arrestments 
of  normal  emlnyologieal  processes ;  they  are  the  expression  of  the 
pathology  of  the  genital  organs  during  the  stage  of  their  evolution  or 
construction  ;  they  represent  morbid  emljryogenesis  ;  and,  judging  by 
what  is  known  of  the  causation  of  malformations  of  other  x>arts  of  the 
Iwdy  in  the  human  subject  and  among  animals,  it  may  lie  presumed 
that  the  disturljance  of  embryogenesis  is  brought  aliout  liy  the  action 
of  traumatism,  microbes,  or  toxines  upon  the  embryo  in  utero. 

But  antenatal  diseases,  as  well  as  antenatal  malformations  of  the 
female  generative  organs,  are  met  with  and  leave  their  impress  upon 
the  later  history  of  the  indi\idual  in  whom  they  occur.  I  have 
recorded  several  cases  (131,  197,  221)  of  tVetal  peritonitis,  and  in  two 
of  these  there  was  displacement  of  the  ovaries  and  Pallopian  tubes  of 
such  a  nature  that,  had  the  infants  lived  to  the  years  of  reproductive 
activity,  they  could  hardly  liave  escaped  much  suffering  during  men- 
struation, and  would  probably  have  lieen  sterile.  F(,etal  pelvic  peri- 
tonitis may  also  lie  instrumental  in  producing  congenital  or  patho- 
logical retroflexion  or  anteflexion  of  the  uterus,  with  or  without 
concomitant  shortness  of  the  vagina  and  conical  cervix  with  pin-hole 
OS  ;  the  far-reaching  effects  of  these  morliid  conditions  are  well  known 
to  every  gynecologist.  Even  prolapsus  uteri,  with  or  without  hyper- 
trophic elongation  of  the  cervix,  has  lieen  found  so  soon  after  birth  as 
to  prove  that  it  existed  potentially  liefore  liirth.  Two  cases  of  this 
congenital  form  of  prolapsus  uteii  were  reported  by  J.  Tin imson  and 
myself  in  1897  (2o)  ;  these  were  the  seventh  and  eighth  known 
examples  of  the  anomaly,  and  since  then  four  or  Ave  further  cases 
have  been  recorded  :  and  it  is  a  striking  fact  that  in  nearly  all  the 
uterine  displacement  coexisted  with  spina  bifida  in  the  lumbo-sacral 
region.  These  occurrences  suggest  that  perhajis  some  of  the  instances 
of  prolapsus  in  the  unmarried  and  in  nulliparous  married  women  may 
have  an  antenatal  origin  or  be  antenatally  predisposed  to ;  and, 
bearing  in  mind  the  association  of  the  prolapsus  with  spina  bifida, 
it  will  lie  well  in  future  to  examine  cases  of  procidentia  and 
descent  of  the  uterus  for  spinal  defects  and  especially  for  spina  liifida 
occulta. 

Even  the  tumours  which  affect  the  female  organs  of  generation 
may  in  some  instances  have  an  origin  in  antenatal  life.  This  is 
especially  true  of  the  deimoid  cysts,  or  teratomata  of  the  ovary.  These 
growths  are  generally  met  with  in  early  reproductive  life,  even  in 
some  cases  in  childhood.  Eecent  researches  have  revealed  the  exist- 
ence of  a  long  series  of  types  of  dermoid  cysts,  showing  all  the 
gradations,  from  a  growth  containing  only  some  hairs  and  skin,  to  one 
containmg  a  rudimentary  liut  perfectly  recognisable  embryo.  Their 
origin  maj'  be  explained  by  regarding  them  as  the  result  of  foetal 
inclusion  or  enclavement,  or  of  parthenogenetic  and  imperfect  seg- 
nientation  of  ova  in  Graafian  follicles :  in  any  case,  the  antenatal 
factor  is  invoked  in  one  form  or   another.      Further,  many  of  the 


26  AN'I'KNAIAI.    I'ATIlOI.OdY    AND    HYCIKNE 

neoi)la.snis  wliit-h  call  for  alidiuuinal  section  for  tlieir  removal  in 
gynecological  i>racLi('e,  ari.so  in  the  cystic  degeneration  of  structures 
which  existed  in  antenatal  life,  and  ought  to  have  completely  atrojihied. 
I  refer  to  jiaruoiilioronic  and  ]>arovarian  cystoniata. 

The  Antenatal  Factor  in  the  Symptomatology  of 
Gynecolog:y. 

It  is  true  that  the  symptuins  that  call  atlentiim  to  the  maladies 
of  the  female  generative  organs  are  usually  separated  hy  a  long 
interval  of  time  from  antenatal  life,  nevertheless  they  are  not  very 
rarely  due  to  conditions  developed  before  hirth.  The  dysmenorrho  a 
and  sterility  associated  with  congenital  Hexions  of  the  uterus,  and 
with  defective  developments  of  the  Graafian  follicles  in  the  ovary 
from  f(ptal  ])elvic  peritonitis,  may  be  justly  ascribed  to  the  antenatal 
factor.  Similarly,  dyspareunia  and  jirofuse  hainorrhage  during  the 
first  attempts  at  coitus  are  sometimes  due  to  antenatal  anomalies  in 
structui-e  or  form  of  the  hymen  and  external  genitals.  Anienorrho->a, 
although  most  frequently  due  to  physiological  conditions,  is  yet  some- 
times caused  by  such  antenatal  states  as  rudimentary  development  of 
the  uterus,  tubes,  and  ovaries,  vaginal  atresia,  or  hymeneal  imjier- 
foration,  in  cases  of  amenoiThcea  in  the  unmarried ;  therefore,  the 
physical  examination  of  the  genitals  ought  not  to  be  too  long  post- 
poned;  for  one  or  other  of  these  congenital  states  may  exist,  and,  if 
this  be  so,  medicinal  treatment  need  be  no  longer  persisted  in  and  time 
wasted.  Irregularities  in  menstruatinn  also  may  be  due  to  malforma- 
tions, especially  of  the  uterus;  thus,  in  the  double  uterus,  menstruation 
may  occur  every  fortnight,  every  month,  or  once  in  two  months. 
Fortnightly  menstruation  may  be  explained  by  the  monthlj-  occur- 
rence of  a  discharge  from  each  horn  of  the  uterus,  the  dates,  how- 
ever, of  the  occiUTence  not  synchronising.  Menstruation  once  in 
twf)  months,  again,  may  be  due  to  a  How  from  one  half  of  a  double 
uterus  at  intervals  of  two  nKJUliis,  the  other  half  of  the  uterus  being 
imperfectly  developed  or  imperforate,  and  therefore  giving  rise  to 
no  discharge.  It  is  possible  that  the  anomalous  form  of  dysmenor- 
rhcea  known  as  the  mid-{)ain,  or  Mittchrhmcrz,  may  be  occasionally 
caused  by  uterine  contractions  in  the  imperforate  half  of  a  double 
uterus,  striving  ineflectually  to  expel  menstrual  blood.  Symptoms 
])oinling  ap])arently  to  disea.se  of  the  nervous  system  may  in  certain 
cases  be  the  result  of  congenital  anomalies  of  the  genital  organs,  such 
as  adhesion  of  the  clitoris,  a  condition  resembling  in  many  ways 
jihimosis  in  the  male.  The  history  of  the  passiige  of  f;eces  from  tlie 
vagina  prf)bably  jioints,  in  the  case  of  the  nullii>ara  at  any  rate,  to 
the  existence  of  the  antenatal  anomalj-  known  as  vulvar  anus. 
IMeeding  from  the  bladder  at  intervals  of  a  month  has  been  known 
to  lie  due  to  vaginal  atresia,  and  the  existence  of  a  congenital  com- 
munication lielween  the  uterus  and  the  liladder.  Examides  miglit 
be  niulti]ilied,  but  sufficient  instiinces  have  been  cited  to  ])rove  that 
even  in  the  sym]ilomatology  of  gynecology  the  antenatal  factor  nnist 
not  be  neglected. 


I 


ANTENATAL   FACTOR   IN   GYNFXOLOGICAL   ETIOLOGY 


The  Antenatal  Factor  in  the  Etiology  of  Gynecology. 

I  have  ah-eady  referred  to  the  presence  of  an  antenatal  factor  in 
the  causation  of  the  malformations  of  the  uterus  and  the  other 
organs  of  generation,  of  the  so-called  pathological  Hexions  of  the 
uterus  and  displacements  of  the  ovaries  and  tubes,  and  of  the 
ovarian  dermoids  and  parovarian  and  paroophoronic  cystomata  ;  but 
there  are  yet  other  gynecological  morbid  states,  of  which  the  cause 
must  lie  looked  for  in  the  life  that  precedes  l.iirth.  For  instance, 
extrauterine  pregnancy  has  recently  had  two  new  theories  advanced 
to  explain  its  etiology,  and  both  of  these  may  Ije  correctly  described 
as  antenatal.  According  to  one,  it  is  occasioned  by  the  presence  of 
an  accessory  tubal  ostium  abdominale  or  of  a  tubal  diverticulum,  and 
cases  have  been  reported  of  ectopic  gestation  in  which  these  mal- 
formations have  been  found  (Henrotin,  F.,  et  Herzog,  Ii'er.  dc  gynic. 
et  dc  chir.  alklom.,  ii.  633,  189S).  According  to  the  other  theory,  the 
power  to  form  a  decidua  is  normally  confined  to  the  mucous 
membrane  of  the  body  of  the  uterus,  but  under  certain  circumstances 
this  power  may  be  po.ssessed  also  by  the  mucosa  of  the  Fallopian 
tube,  for  both  the  tube  and  the  uterus  are  derived  from  the  duct  of 
Mtiller:  it  may  be  that  through  an  arrest  of  the  development  of 
the  tulial  mucous  membrane  it  retains  this  decidual  reaction  or 
power  of  responding  to  the  genetic  influence  by  the  occurrence  of 
decidual  changes.  As  it  has  been  stated  by  J.  C.  Webster 
("Ectopic  Pregnancy,"  12,  1895),  "this  is  probably  because  of  some 
developmental  fault,  whereby  there  is  reversion  either  of  structure 
or  reaction  tendency  in  the  tubal  mucosa  to  an  earlier  type  in 
mammalian  evolution — I  mean  that  in  which  a  larger  portion  of  the 
Miillerian  ducts  showed  decidual  reaction." 

Even  tibro-myomata  of  the  uterus  have  of  late  years  come  to  be 
regarded  as  occasionally  due  in  some  measure  to  antenatal  causes, 
and  a  very  curious  family  history  of  the  heredity  of  tiViroids  has  been 
put  on  record  by  T.  Spannochi  {Annali  di  ostetricia  e  ginecologia, 
xxi.  331,  1899).  "  There  were  three  brothers,  called  M.,  S.,  and  P. ; 
of  these  M.  and  S.  married  two  sisters,  A.  and  B.  The  descend- 
ants of  M.  and  A.  were  free  from  abdominal  tumours,  but  those 
of  S.  and  B.  showed  in  a  very  striking  way  the  tendency  to 
uterine  fibroids,  and  also  to  heart  disease.  There  were  nine 
children,  of  whom  seven  were  females,  and  of  the  seven  four  had 
fibroids,  and  two  had  also  concomitant  heart  disease,  while  one  of 
the  three  who  had  not  fibroids  had  a  daughter  who  developed  a 
filiroid ;  and  of  the  four  daughters  who  suffered  from  fibroids  one  had 
three  daughters,  all  of  whom  had  fibroids  and  lieart  disease,  and  of 
these  two  were  twins.  The  third  brother.  P.,  married  a  woman,  E., 
not  related  to  A.  and  B. :  there  were  five  daughters  and  six  sons  from 
this  marriage,  in  which,  let  it  be  remembered,  that  the  mother  had 
no  fibroid  lierself ;  two  of  the  daughters  had  filii-oids,  while  a  third 
suffered  from  heart  disease,  and  gave  birth  to  three  daughters,  one  of 
whom  suffered  from  a  fibroid  :  further,  one  of  the  six  sons  married 


28  ANTKNAlAl,    I'ATHOLOdY    AND   HV(;1KNK 

ami  lieyat  a  diuigliter,  wlio  had  botli  a  Kbroid  tuiiimir  of  tlie  uterus 
and  a  t-vst  nf  the  ovary,  and  she  in  lier  turn  'j,;ivc  birtli  to  three 
daughters,  one  of  whom  liad  now  been  operated  u])on  for  a 
uterine  tibro-inyoma.  In  this  remarkable  family  history,  not  onlj* 
does  there  seem  to  have  lieen  a  tendency  to  the  production  of 
female  children,  with  a  predisposition  to  develop  fibroids ;  but 
this  tendency,  curiously  enough,  seems  to  have  been  transmitted 
through  the  males,  for  it  affected  the  progeny  of  two  brothers 
married  tn  women  of  different  families,  and  again  one  of  tlie  sons 
handed  it  on  to  his  daughter.  T])c  association  of  heart  disease  in  the 
family  pathological  legacy  is  also  of  interest,  as  is  the  twin-bearing. 
Of  course,  this  antenatally  transmitted  tendency  to  produce  fibroids 
is  not  incompatible  with  the  theory  of  origin  of  such  tumours  from 
the  muscular  coat  of  the  small  uterine  arteries  or  from  proliferating 
congenital  germs.  It  may  be  objected  that  uterine  fibroids  are  so 
common  in  women  that  the  occurrence  of  them  in  the  above  history 
might  be  ex]ilained  in  that  way;  but  the  ordinary  degree  of  frequency 
of  noticeable  and  symjitom-producing  myomata  is  not  nearly  so 
great  as  that  which  prevailed  in  the  progeny  of  S.  and  1'.  with  B. 
and  E.  Engstrom  {Finska  Lukaresulhkapets  Handlingar,  No.  12, 
1899)  has  also  noted  family  jirevalence  and  heredity  in  cases  of 
myoma  uteri ;  in  eight  instances  two  sisters  were  affected,  in  one 
instance  three  sisters,  in  two  instances  two  sisters  and  their  mother, 
in  one  instance  three  sisters  and  their  mother,  and  in  yet  another 
instance  four  sisters  and  their  mother,  had  uterine  fibroids. 

In  this  relation  reference  may  also  be  made  to  the  curious  family 
histories  in  which  all  the  female  offspring  either  develo2)ed  cancer  or 
were  twins :  and  this  is  but  another  suggestion  that  cancer  or  the 
tendency  to  it  is  prenatally  predisposed  to.  Deciduoma  malignum 
stands  in  an  altogether  peculiar  relation  to  antenatal  life.  It  would 
seem,  according  to  one  theory  of  origin  at  any  rate,  to  he  the  result 
of  an  engrafting  of  the  remains  of  an  abnormal  antenatal  formation, 
the  syncytium  of  a  hydatid  mole,  in  the  wall  of  the  maternal  uterus. 
It  is,  therefore,  the  consequence  of  abnormal  developments,  not  in 
the  antenatal  life  of  the  woman  who  suffers  (and  may  die)  from  it, 
but  in  that  of  her  progeny  in  utero. 

The  Antenatal  Factor  in  Gynecological  Diagnosis. 

It  is  jierhaps  unnecessary  to  insist  upon  the  necessitj-,  in  making 
a  diagnosis  in  a  gynecological  case,  to  keep  in  mind  the  possible 
presence  of  antenatal  malformations  of  the  genital  organs;  at  the 
•same  time  many  of  these  malformations  are  so  rare  that  even  an 
experienced  gynecologist  may  not  liave  had  the  chance  of  seeing 
more  than  one  or  two  of  them  in  a  life-time.  Further,  the  medical 
periodicals  contain  not  infrc(iuent  records  of  errors  in  diagnosis  which 
havearisen  through  a  wantof  a  just  recognition  of  the  ])ossiliility  of  the 
antenatal  factor.  Thus  the  abdomen  has  been  o]iened  for  the  removal 
of  a  uterine  or  ovarian  tvunour,  to  find  a  pregnancy  in  the  rudimentary 
half  of  a  uterus  bicornis ;  fibroids  of  the  uterus  have  been  mistaken 


r 


( 


THK   ANTENATAL   FACTOR    IN    GYNEC()L()(;V  29 

for  inalforinatinns  of  that  organ,  and,  more  frequently,  nialfurmations 
liave  been  mistaken  for  fibroids ;  and  atresia  of  the  vagina  leading  to 
hiematometra  has  been  diagnosticated  (through  insufficient  examina- 
tion) as  a  normal  pregnancy,  and  has  led  to  unjust  imputations  upon 
the  moiul  character  of  the  girl  who  has  been  the  subject  of  the 
vaginal  anomaly.  But  doubtless  the  worst  errors  in  diagnosis  have 
been  due  to  the  non -recognition  of  male  pseudo-hermaiihrodites  in 
early  life.  The  association  of  amenorrhoea  with  the  secondary  sex 
characters  of  the  male  in  an  individual  apparently  of  the  female  sex 
should  always  excite  the  suspicion  of  the  gynecologist  who  may  be 
consulted,  and  he  ought  to  insist  upon  a  physical  examination  of  the 
patient.  J.  Halliday  Croom  {Trans.  Edin.  Obsi.  Soc,  xxiii.  p.  102, 
1899)  and  Chiarleoni  (Gi/ni'cologic,  v.  p.  55, 1900)  have  both  reported 
cases  in  which  supposed  sisters  turned  out,  on  physical  examination, 
to  be  really  hypospadiac  brothers.  It  is  interesting  to  note  the 
family  prevalence  in  these  two  cases,  for  in  this,  as  in  other  morbid 
states  which  the  gynecologist  may  be  called  upon  to  diagnose,  more 
than  one  member  of  the  same  family  may  lie  affected  with  the  same 
condition.  Thus,  Lolilein  {Monats.  f.  Geburts.  u.  Gynclk.,  iii.  p.  91, 
1896)  has  referred  to  an  instance  in  which  three  sisters  all  suffered 
from  bilateral  ovarian  cystoma,  and  in  two  of  them  development 
of  tlie  cyst  was  liomochronous,  i.e.  commenced  when  the  patient 
reached  the  same  age  in  life. 

It  is  well  to  bear  in  mind  that  truly  antenatal  anomalies  of  the 
genitals  are  apt  to  be  found  in  association  with  want  of  postnatal 
sexual  evolutionary  change,  and  with  minor  malformations  of  the 
other  parts  of  the  body.  Women  showing  this  condition  of  infantilism, 
as  it  has  been  termed,  may  therefore  be  expected  to  possess  a  more  or 
less  malformed  uterus,  and  tubes,  and  ovaries,  an  important  fact  for 
the  gynecologist  to  remember.  They  present  the  picture  of  a  weakly 
vertebral  column,  with  a  marked  anterior  concavity ;  a  narrow  or 
kyphotic  pelvis ;  flat  nates,  and  a  slightly  marked  mons ;  poorly 
developed  labia  majora  leaving  the  labia  minora  and  clitoris  exposed  ; 
a  vagina  with  some  traces  of  its  original  duplicity ;  a  congenitally 
anteflexed  iiterus  with  a  cervix  showing  a  long  posterior  lip  and  a 
shorter  anterior  one,  leading  to  a  long  and  curved  cervical  canal,  and 
a  small  corpus  with  a  thick  and  convex  posterior  wall,  and  a  thinner 
and  concave  anterior  one ;  Fallopian  tubes  showing  fretal  spirality ; 
tliin  ligamenta  rotuuda  and  small  pointed  ovaries :  a  cylindrical 
liladder,  with  a  pointed  urachal  end ;  a  narrow  rectum ;  lij'poplasia 
of  the  heart  and  aorta ;  a  marked  representative  of  the  thymus 
gland ;  a  small  and  transversely  placed  stomach ;  a  long  vermiform 
appendix  with  a  wide  entrance  and  lobulated  kidneys  (W.  A.  Freund, 
Samml.  Jdin.  Vortrclge,  Gynakologiv,  No.  93,  p.  2338,  1888).  In  the 
presence,  therefore,  of  a  woman  with  such  a  habitus,  the  gynecologist 
will  be  able  to  form  a  provisional  diagnosis  of  the  state  of  the  internal 
organs,  and  may  simplify  the  further  management  of  the  case. 


30  ANTENATAL    I'ATHOlXKiV    AND    lIVdlKNK 


The  Antenatal  Factor  in  Gynecological  Prognosis. 

The  iuiti'iiatal  factor  lias  occasLoiiiiUy  intervened  in  a  suniewliat 
unexpected  fashiou  in  gynecological  prognosis.  Thus,  a  case  (ISlondel, 
Ann.  de  i/i/inr.,  1.  137,  1898)  was  reported  in  1898  in  which  an 
operator,  engaged  in  curetting  a  uterus,  thought  that  he  felt  the 
curette  pass  tiirough  tlie  wall  of  the  organ ;  in  alarm  lie  ceased 
iiis  interference,  and  awaited  results  with  considerable  fear;  but 
no  ill  eft'eels  followed,  and  on  a  subsequent  occasion  he  discovered 
that  he  had  lieen  dealing  with  a  double  uterus,  and  that  the  curette 
had  simply  passed  from  one  cavity  of  the  viscus  into  tiie  other, 
giving  to  the  hand  of  the  operator  the  sen.sation  of  perforation.  The 
removal  of  the  ovaries,  to  induce  a  premature  menopause  in  cases 
of  uterine  h;emorrhage  and  in  some  kinds  of  nervous  disease,  has  not 
always  been  followed  by  the  anticipated  results,  and  it  has  been 
suggested  that  sometimes  the  error  in  prognosis  has  been  the  outcome 
of  the  existence  of  an  accessory  ovary  or  of  a  constricted  piece  of  an 
ovary.  It  must  not  he  foi'gotten  that  in  gynecology,  as  in  other 
dejiartments  of  medicine,  antenatal  conditions  have  seldom  so  hopeful 
a  prognosis  as  have  the  maladies  which  are  developed  during  post- 
natal life;  instances  of  this  are  forthcoming  in  the  congenital  dis- 
placements of  the  uterus,  and  in  malformations  of  that  organ  and  of 
the  ovaries.  Freund  (Lor.  cit.  SKjira)  specially  dwells  ujion  the  prog- 
nostic importance  of  evolutionary  anomalies  of  the  Fallo]iian  tubes  in 
the  diseases  of  these  structures  which  arise  in  later  life.  For  instance, 
if  the  tubes  retain  the  fu?tal  spirality,  which  normally  reaches  its 
maximum  degree  about  the  thirty-second  week  of  antenatal  existence, 
it  will  not  only  interfei-e  with  the  normal  function  of  the  tubes  in 
adult  life,  but  will  seriously  modify  the  chances  of  successful  treatment 
of  diseases  arising  in  the  tulies  from  other  causes.  Secretions,  both 
normal  and  pathological,  will  tend  to  accumulate  in  such  twisted 
organs,  and  so  infection  will  more  readily  occur,  or,  having  already 
occurred,  will  be  more  intense  and  more  widely  diffused.  Freund 
does  not  hesitate  to  divide  all  the  diseases  of  the  Fallopian  tul>es 
into  two  classes,  those  with  and  these  without  developmental 
anomalies:  tiie  prognosis  for  all  things  is  worse  in  the  former  than 
in  the  latter. 

The  Antenatal   Factor   in   Gynecological   Therapeutics. 

Considerable  progress  has  been  made  in  the  rectification  of  the 
malformations  of  the  genital  organs  which  arise  from  antenatal 
causes.  The  operation  for  imperforate  hymen  may  be  described  as 
perfected,  and  the  treatment  of  atresia  vulva'  superficialis  may  also 
be  regarded  as  satisfactory.  Further,  recent  improvements  in  the 
management  of  atresia  vagin;e  and  of  vulvar  anus  have  been  intro- 
duced;  and  it  may  l)e  noted  that  the  opening  into  tlie  ]ieritoneal 
cavity,  once  so  dreaded  in  the  operation  for  the  construction  of  an 
artificial  vagina,  is  now  rather  the  auxiliary  object  aimed  at  than 


I 


ANTKNATAL    lACTOU    IN    (iYNEC'OLOCV  ;jl 

the  contretdiips  avoided.  At  any  rate,  it  is  found  advantageous 
to  open  into  the  pouch  of  Douglas,  in  order  to  determine  at  once  the 
condition  of  the  uterus  and  ovaries,  and  tiuis  gain  a  guide  as  to  the 
future  steps  of  the  operation  (27).  It  must,  however,  be  confessed 
that  much  still  remains  to  be  done  in  the  reparative  surgery  of 
antenatal  defects  of  the  genital  organs  in  women.  Even  in  the 
management  of  the  congenital  flexions  of  the  uterus  and  of  the  results 
of  ftetal  peritonitis  there  is  great  roi:)ni  for  improvement  in  present- 
day  therapeutics.  Xot  only  are  the  embryonic  malformations  and 
the  fo?tal  diseases  of  the  genital  organs  difficult  in  themselves  to 
treat,  but  the  inflammatory  and  (.)ther  morbid  eonditinns  of  these 
parts  which  arise  in  later  life  are  always  less  tractable  when  associated 
with  these  antenatal  anomalies.  For  instance,  salpingitis  is  a  more 
formidable  process,  and  requires  a  more  radical  method  of  treatment, 
when  it  is  found  in  a  tube  with  the  spiral  twists  of  ftetal  life  fully 
preserved.  "When  the  normal  process  of  pregnancy  takes  place 
abnormally  in  the  rudimentary  horn  of  a  bicornate  uterus,  it  calls  for 
the  same  interference  as  does  the  worst  case  of  ectopic  gestation. 

The  problem  of  the  prevention  of  the  malformations  of  the  uterus 
and  its  anne.xa  has  scarcely  yet  been  seriousl}'  investigated,  for  the 
sutficient  reason  that  little  has  been  known  of  the  mode  of  origin  of 
these  anomalies.  Of  course,  it  has  been  recognised  that  arrest  in 
the  normal  process  of  development  of  the  ducts  of  Miiller  and  of  the 
mesonephros  and  the  anlage  of  the  ovaries,  explains  the  nature  of 
most  of  the  malformations ;  but  in  the  absence  of  information  con- 
cerning the  causes  of  the  arrest,  this  knowledge  avails  little.  Some 
light,  perhaps,  has  of  late  years  been  thrown  upon  the  whole 
question  of  malformations  and  monstrosities,  jnore  especially  by  the 
methods  of  experimental  teratogenesis ;  and  clinical  observation  has 
so  far  given  some  support  to  the  conclusions  thus  arrived  at,  namely, 
that  malformations  are  due  to  the  causes  of  disease  acting  on  the 
organism  during  the  embryonic  or  formative  period.  It  is  therefore 
to  be  expected  that  it  will  yet  be  shown  that  microbes  and  their 
toxines,  and  toxic  agencies  such  as  alcohol  and  lead  and  other 
poisons,  and  possibly  also  traumatism,  are  the  ultimate  causes  of 
malformations.  It  may  also  be  expected,  therefore,  that  the 
anomalies  of  the  genital  organs  will  be  more  commonly  met  with 
in  the  descendants  of  parents  who  have  been  alcoholic,  syphilitic, 
tuberculai-,  or  otherwise  unhealthy.  The  true  antenatal  therapeutics 
of  gynecology  will  therefore  come  to  be  the  prevention  of  the  causes 
of  disease  in  the  preceding  generation  and  the  raising  of  the 
standard  of  health  in  marriage.  In  this  respect  the  antenatal  factor 
in  gynecological  therapeutics  does  not  differ  from  that  in  general 
therapeutics. 

The  Antenatal   Factor  in  Gynecological  Jurisprudence. 

Certain  questions  in  medical  jurisprudence  in  which  the  antenatal 
factor  plays  a  part  have  already  been  alluded  to,  namely,  the  registra- 
tion of  the  sex  of  pseudo-hermaphrodites,  nullity  of  marriage  for 


32  AMl'.NAI'AI,    I'ArilOl.OCY    AM)    IlYdllAK 

malformation,  etc. ;  hut  tliere  are  several  other  <iuestions,  besides 
those  connected  with  individuals  of  doubtful  sex,  wliicli  may  come 
into  tlie  law  courts  and  reiiuire  an  answer  from  tiie  specialist  in 
gynecology.  It  lias,  for  instance,  been  affirmed  that  a  woman  with 
a  split  or  lacerated  cervix  uteri  must  have  been  pregnant  at  one  time 
or  another  ;  but  it  is  plain  that  she  might  have  had  the  cei'vix  split 
artiticially  to  permit  the  removal  of  a  filjroid  tumour  i>r  intrauterine 
polypus.  It  is  not,  liowever,  so  plain  or  so  generally  known  that 
laceration  of  tlie  cervix  may  be  present  in  a  new-born  infant  as  a 
congenital  condition :  yet  this  is  true,  for  Penrose  (American  J.  Med. 
He.  X.S.,  cxi.  50:3,  189«),  Jettenson  {Med.  Sentinel,  iv.  552,  189G),  and 
Kd wards  ("Keating's  Cyclopadia  of  the  Diseases  of  Cliildren,"  v.  899, 
1899)  liave  all  met  with  undoubted  cases  of  congenital  split  of  the 
cervix  uteri  witli  erosion.  Tlie  condition  is  proliably  an  abnormality 
in  the  arrangement  of  tlie  mucous  membrane  of  the  cervical  canal,  a 
congenital  histological  ectrojjion.  In  addition  to  its  purely  medico- 
legal importance,  it  may  also  be  that  congenital  laceration  of  the  cervix 
has  some  bearing  upon  the  later  development  of  cerviciil  erosions  in 
women,  and  even  upon  the  origin  of  cancer  of  the  cervix  uteri.  One 
must  take  great  care  in  the  witness-box  not  to  be  too  emphatic  in 
stating  which  structural  conditions  may  and  which  may  not  be  com- 
patible with  chastity.  As  has  been  shown,  even  prolapsus  uteri  may 
be  met  with  in  an  infant  of  a  few  hours  ! 

There  is,  therefore,  in  many  directions  a  projection  of  Antenatal 
Pathology  into  gynecology,  although  years  must  elapse  before  the 
results  of  the  events  which  occur  before  birth  are  seen  in  tlie 
consulting-room  of  the  gynecologist. 


I 


CHAPTER    IV 

The  Immediate  Efl'ect  of  Antenatal  Pathology  ;  Tlie  Antenatal  Factor  in  Neonatal 
Pathology.  The  Neonatal  Period  of  Life  ;  Physiology  of  Neonatal  Life  ; 
Physiological  Traumatism  of  Birth,  including  the  Pressure  Effects  and  the 
Sejjaration  Effects ;  Physiological  Keadjustment  at  Birtli,  and  its  Intiuence 
upon  the  Characters  of  the  JIaladies  of  the  New-born  Infant ;  Anatomical 
Readjustment ;  The  Antenatal  Factor  and  its  Intiuence  upon  Neonatal 
Pathological  Processes. 

As  has  been  pointed  out  in  the  preceding  chapter,  the  effect  which 
antenatal  morbid  states  exert  upon  gynecological  disorders  is  a 
jDostponed  one  and  is  not  manifested  for  many  years,  during  which  the 
genital  organs  and  their  abnormal  or  normal  potentialities  are  dor- 
mant. In  this  and  in  the  following  chapters  fall  to  be  considered  the 
immediate  effects  of  antenatal  pathological  conditions,  those  which 
have  a  bearing  upon  the  characters  of  the  diseases  of  the  new-born 
infant. 

On  the  dividing  line  between  Antenatal  and  Postnatal  Pathology 
lies  Neonatal  Pathology,  a  sort  of  unexplored  territory,  a  "  No  Man's 
Land,"  liable,  however,  to  incursions  from  both  sides,  those  of  the 
weaker  kind  coming  over  the  antenatal  boundary.  Between  the 
surgical  injuries  and  maladies  of  the  life  that  is  after  birth,  and  the 
diseases  and  deformities  of  the  fojtus  and  embryo,  are  situated  the 
morbid  conditions  of  the  new-born  infant,  conditions  which  interest 
both  the  pediatrist  and  the  oljstetrician.  Investigation  of  them  has 
indeed  gone  on  from  lioth  the  pediatric  and  the  obstetric  standpoint,  but 
with  more  activity,  it  has  seemed,  from  the  former  than  from  the  latter. 
Nevertheless,  it  is  well  to  bear  in  mind  that  the  maladies  of  the  new- 
born have  relations,  not  only  with  the  diseases  which  occur  later,  but 
also  with  the  pathological  states  which  have  happened  earlier  in  life. 
Just  as  neonatal  life  is  the  link  between  j)ostnatal  and  antenatal  life, 
so  Neonatal  Pathology  is  the  link  lietween  Postnatal  and  Antenatal 
Pathology.  It  offers  problems  for  solution  which  require  that  we 
take  into  account  both  the  conditions  which  precede  and  those  which 
follow  birth ;  its  study,  further,  is  helpful  in  throwing  light  on  them 
Iioth.  That  neonatal  morbid  states  offer  jieculiarities  of  a  very 
marked  kind  hardly  calls  for  proof.  It  need  only  be  pointed  out 
that,  in  order  to  emphasise  these  peculiarities,  a  nomenclature  has 
come  into  use  which  adds  to  the  name  of  the  disease  the  word  "  neo- 
natorum." In  this  way  the  terms  "cephalh;ematoma  neonatorum,"  "pem- 
phigus neonatorum,"  "icterus  neonatorum,"  "mekena  neonatorum," 


:j4  ANTIAATAL    I'A  TllOLOCiV    AM)    IIVOIENI'. 

ami  uiany  others  have  got  a  place  in  medical  terminology.  Sometimes 
the  word  is  "  nascentiiim,"  as  in  "  trismus  nascentium,"  Imt  the 
meaning  is  the  same.  That  iicculiarities  exist  is  not  (jiiestioned,  but 
attempts  to  explain  them  have  not  been  altogether  satisfactory ; 
possibly  this  failure  has  been  due,  in  part  at  least,  to  the  want  of 
recognition  of  the  antenatal  element  in  their  origin.  It  w-ill  be  well 
to  consider  the  various  possible  influences  which  may  determine  the 
characters  of  the  maladies  of  the  new-born  infants,  and  among  them 
the  auteualal  iufluenee. 

The  Neonatal  Period. 

In  every  period  of  life  physiology  largely  dominates  patho- 
logy; the  diseases  of  the  child  or  of  the  aged  relleet  in  their 
characters  the  physiology  of  childhood  or  of  old  age.  The  age 
peculiarities  of  di.sease  are  in  great  measure  the  expression  of  the 
age  peculiarities  of  health.  The  greater  the  ditl'erence  between  the 
pliysiological  conditions  of  two  epochs  of  life,  the  greater  will  be 
the  (iifCerences  between  their  pathological  manifestations.  The  physio- 
logy of  the  new-born  stands  out  very  prominently  from  that  of  all 
other  periods  of  extrauterine  life,  and  in  like  manner  its  pathology 
differs  markedly  from  that  of  childhood,  adult  life,  and  age. 

Physiology  of  Neonatal   Life. 

The  period  of  life  which  has  been  termed  that  of  the  new-born 
infant  may  lie  regarded  as  beginning  with  the  first  maternal  labour 
pain,  and  ending  about  the  close  of  the  Hrst  month  of  infantile  life. 
It  includes,  therefore,  a  period  of  time  which  may  be  called  intranatal, 
that  during  which  the  infant  is  passing  through  the  birth  canal ; 
and  another,  truly  neonatal,  during  which  the  infant's  body  is  adapt- 
ing itself  to  its  new  environment.  These  two  periods  of  the  infant's 
life  correspond  in  time  to  the  periods  of  laljour  and  the  jiuerperium 
in  the  mother's  life ;  it  is  for  this  reason  that  sepsis  of  the  new- 
born infant  has,  somewhat  unfortunately,  been  termed  by  some  writers 
"  puerperal  sejisis  "  of  the  infant,  "  sepsis  neonatorum  "  being  a  name 
in  every  way  iireferable.  The  intranatal  period  is  of  varying  length 
(from  a  few  hours  to  two  or  three  days),  but  is  always  much  shorter 
than  the  truly  neonatal  period.  Theoretically,  it  may  be  objected  that 
the  intranatal  and  neonatal  periods  ought  not  to  be  ]iut  together  under 
the  one  heading  of  neonatal,  as  they  are  separated  by  the  momentous 
occurrence  of  the  conuueneement  of  extrauterine  life  ;  Init,  practically, 
there  is  no  sharp  line  of  demarcation,  for  the  infant,  during  his 
passage  through  the  birth  canals,  may  use  his  lungs  iu  breathing, 
may  pass  meconium  and  urine,  and  may  even  cry  before  he  is  quite 
free  of  the  vagina.  Further,  the  two  epochs  are  very  closely 
ctmnected,  the  neonatal  being  the  complement  and  continuation 
of  the  intranatal ;  the  infant  during  his  neonatal  life  is  occupied 
in  recovering  from  the  effects  of  his  birth,  or,  we  may  say,  in 
learning  to  utilise  the  possibilities  thrust  upon  him  by  his  birth. 


TRAUMATISM    OF    151 KTH  35 

Neonatal  life  is  the  period  of  adaiitatiou  to  the  new  conditions 
brought  aliout  Ijv  intranatal  life.  We  may  call  tlie  morbid  phe- 
nomena of  this  period  of  life  "  intranatal "  or  "  neonatal "  pathology  ; 
it  matters  not  which,  so  long  as  we  realise  that  they  possess  characters 
which  are  in  many  ways  peculiar. 

Physiological  Traumatism  of  Birth. 

To  the  infant  the  intranatal  period  of  his  life,  short  thougli  it  be, 
is  one  of  much  strain  and  stress.  Is  is  true  that  he  does  not,  as 
was  erroneously  supposed  by  the  ancients,  have  to  make  his  way, 
liy  his  own  little  aided  efforts,  to  the  world  outside  the  womb; 
and  nowadays  we  do  not  admit  that  he  has  much  to  do  witli 
his  birth,  save  in  a  sort  of  passive  fashion,  by  means  of  his 
weight  of  9  lb.  or  less,  which,  by  gravity,  may  possibly  to  some 
slight  extent  expedite  his  progress,  if  his  mother  be  erect;  but, 
none  the  less,  his  transit  from  intrauterine  to  extrauterine  sur- 
roundings is  to  him  an  eventful  and  often  a  dangerous  time.  By 
uterine  efforts,  the  sum  total  of  which  is  by  no  means  inconsiderable, 
he  is  propelled  through  curved  canals,  with  unequal  diameters, 
encountering  no  little  resistance  by  the  way.  His  body  is  not  a 
plastic  mass ;  but  it  is  capable  of  a  certain  degree  of  moulding, 
even  in  its  hardest  part,  the  head ;  and  the  maternal  canals,  which 
are  denominated  soft,  ai'e  in  their  turn  slightly  moulded  by  the 
foital  structures  which  they  surround.  Thus,  by  means  of  uterine 
propulsive  forces,  with  the  help  of  head  and  body  moulding,  the 
ftetus  is  driven  along  the  canals,  undergoing  some  rotation  in  his 
passage,  and  expelled  into  a  new  and  trying  environment.  Birth, 
then,  without  being  abnormally  difficult,  is  the  traumatic  transition 
from  an  intrauterine  to  an  extrauterine  existence ;  this  may  be 
termed  the  physiological  traumatism  of  birth.  Under  certain  cir- 
cumstances, as  in  the  multipara  with  a  large  roomy  pelvis  and  a 
fu;'tus  of  moderate  dimensions,  the  traumatism  is  reduced  to  a 
minimum ;  possibly  at  one  time  in  the  history  of  the  human  race 
there  was  little  or  no  traumatism  at  all ;  but  the  effects  of  civilised 
life  and  other  causes  have  exacted  payment  in  the  form  of  increased 
birth  traumatism,  and  to  this  the  headward  development  of  the 
fcctus  has  in  no  small  degree  added.  Natural  labour,  then,  is  a 
traumatism  ;  not,  of  course,  a  necessarily  or  even  probably  fatal  one  ; 
but  none  the  less  a  traumatism.  It  will  be  convenient  here  to  look 
a  little  more  particularly  at  the  details  of  this  traumatic  transition. 

It  consists,  in  the  first  place,  of  the  effects  produced  by  pressure 
upon  the  fcetus,  and  more  especially,  but  not  solely,  upon  the  head 
of  the  fcetus ;  and,  in  the  second  place,  of  the  separation  of  parts 
in  structural  and  vital  continuity,  with  resulting  h;cmorrhage.  The 
pressure  effects  may  be  described  as  contusions,  and  the  separation 
results  as  injuries  to  the  effusion  of  blood. 

1.  The  pressure  effeets  of  labour  are  most  evident  upon  the  foetal 
head,  for  in  the  large  proportion  of  cases  it  passes  first  through  the 
canals ;  and  for  the  reason  that  it  is  resistant  to  pressure  and  has  large 


36  ANTENATAL    l'Alll()l.()(;V    AND    1 1'>(  ill-.NK 

diameters.  The  effects  consist  of  the  fipiinatiou  nf  tlie  uaput  suc- 
cedaneum,  or  Ijirth  -  bruise,  and  the  nioidding  of  the  head,  with 
disi)lacement  of  the  bones.  The  former  is  the  serous  or  sero- 
sauguineous  effusion,  which  takes  place  into  the  tisstie  of  the  skin 
of  the  presentini;  part  of  tiie  fn'tus;  usually  the  area  of  tin'  cranium 
in  the  neighbourhood  of  the  posterior  fontanelle,  which  lie-;  within 
the  girdle  of  contact  of  the  maternal  canals.  Every  part  of  the 
surface  of  the  foetus  save  this  is  under  great  pressure,  so  into  tliis 
unsupported  part  the  effusion  of  serum  takes  place.  It  forms,  as 
might  be  expected,  during  the  second  stage  of  labour;  but  it  is 
noteworthy  that  it  has  lieen  found  occasionally  before  the  rupture 
of  the  membranes  (Barbour.  A.  H.  F.,  "Anatomy  of  Labour."  2nd 
edition,  p.  192,  1899).  It  differs  from  the  ordinary  postnatal  bruise, 
in  being  the  result,  not  of  pressure  applied  directly  to  it,  and 
quickly  removed,  but  of  long  -  continued  circumferential  pressure ; 
nevertheless,  it  is  essentially  a  contusion.  Further,  there  is  some 
reason  to  believe  that  it  is  sometimes  caused  by  direct  pressure 
also  ;  but  this  is  exceptional.  The  epidermis  covering  it  is  often 
found  raised  in  blelis,  or  separated  altogetlier.  When  the  face 
presents,  the  caput  forms  over  the  cheek,  the  eyelids  are  swollen 
and  discoloured,  and  there  is  congestion  of  the  conjunctiva;  but 
the  nose  and  chin  are  not  much  affected,  as  the  skin  is  there  tightly 
fixed  to  the  underlying  parts.  The  caput,  in  ordinary  labour, 
elongates  the  cephalic  ovoid,  and  in  some  measure  serves  a  useful 
purpose  in  the  mechanism  of  parturition ;  but  the  greater  part 
of  the  moulding  of  the  head  is  due  to  changes  in  the  relation 
of  the  cranial  bones  to  each  other.  In  a  communication  on  the 
"Head  of  the  Infant  at  Birth,"  made  to  the  Edinliurgh  (Obstetrical 
Society  some  years  ago  (37),  I  gave  a  series  of  cranial  measurements, 
which  showed  that  five  or  six  days  require  to  elapse  after  birth 
before  the  head  returns  to  the  form  which  it  had  anterior  to  the 
commencement  of  labour.  To  ascertain  the  shape  of  the  unmoulded 
head,  I  took  the  head  diameters  of  infants  removed  bj'  tlie  Ciisarean 
sectitm ;  of  ftetuses  in  puldished  cases,  where  maternal  death  had 
occurred  in  the  later  months  of  pregnancy,  and  where  frozen 
sections  had  been  made ;  and  of  an  infant  removed  post-mortem 
from  the  uterus  of  a  woman,  who  had  died  of  pneumonia  before 
labour  set  in.  It  appeared  that,  although  the  heads  differed  in 
actual  size,  their  cranial  diameters  (maximum,  occipito-mental, 
occipito-frontal,  suboccipito-bregmatic,  biparietal,  and  liitemjioral), 
all  had  the  same  relative  lengtii,  l)ore  the  same  proportion  to 
each  other.  T  then  measured  a  series  of  heads,  at  or  soon  after 
birth,  and  found  that  these  cranial  diameters  no  longer  had  the 
same  relation  to  each  other :  in  all  the  cases  there  was  a  diminu- 
tion in  the  occipito-mental,  occipito-frontal,  and  suboccipito-bregmatic 
diameters,  and  an  increase  in  the  maximum.  In  other  words,  the 
birth  traumatism  had  produced  a  compression  of  tiie  head  in  tiie 
suboccipito-bregmatic  plane,  and  a  com]»ensatory  enlargement  in  the 
plane  of  the  maximum  diameter.  This  moulding  of  the  fo'tal  head 
is,  as  is  well  known,  due  to  the  overlapping  of  the  bones  at  tlie 


TRAUMATISM    OF   BIRTH  o? 

sutures  (one  parietal  over-rides  the  other  at  the  sagittal  suture, 
the  two  halves  of  the  frontal  underlie  the  contiguous  parietals 
anteriorly,  and  the  occiput  underlies  the  parietals  posteriorly) ; 
and  it  is  accompanied  by  a  bulging  of  one  side  of  the  liead  (that 
which  lies  anterior  in  the  mother's  pelvis)  producing  asymmetry. 
So  constant  is  this  head-moulding,  that  it  forms  part  of  the  jihysio- 
logical  traumatism  of  1  )irth ;  but  it  is  very  certain  that  the  same 
amount  of  distortion  of  parts,  occurring  at  a  later  period  of  life, 
would  be  termed  pathological.  At  the  end  of  about  a  week  the 
head  has  again  taken  its  normal  (or  antenatal)  form ;  the  effects 
of  the  birtli  -  traumatism  have  then  passed  off,  and  the  cranial 
diameters  have  regained  their  antenatal  relative  length. 

To  a  less  evident  extent  the  pressure  effects  are  visible  upon 
the  trunk  of  the  fcetus.  At  the  end  of  pregnancy  (as  Barbour 
describes  it,  o/a  cif.,  p.  23),  "the  general  contour  of  the  fa-tus  is 
an  oval,  of  which  the  long  axis  is  not  greatly  in  excess  of  the 
short ;  the  flexures  of  the  different  parts  are  not  acute,  the  limbs 
being  not  compressed ;  but,  so  to  speak,  comfortably  disposed,  and 
the  spine  gently  curved."  In  the  second  stage  of  labour  all  this 
is  changed,  for  the  foetal  contour  is  now  an  elongated  oval,  the 
flexures  of  the  limbs  are  increased,  and  the  appearances  suggest 
compression,  the  outlines  being  more  regular.  The  firessure  effects 
upon  the  fcetal  trunk  and  limbs  disappear  almost  immediately  after 
birth,  and  in  this  respect  contrast  witli  the  head  changes.  When 
any  part  of  the  trunk  presents  {e.g.  breech,  shoulder)  a  caput  suc- 
cedaneum  forms  upon  it;  but  even  iu  this  respect  the  deformity 
thus  produced  is  much  more  transitory  than  that  seen  in  the 
case  of  the  head.  Such  are  the  plastic  phenomena  of  the  birth 
traumatism. 

2.  The  reparation  results  of  the  physiological  traumatism  of 
birth  have  an  importance  not  less  than  that  of  the  pressure  effects. 
In  some  of  the  mammalia  placentalia  the  connection  between  the 
maternal  and  foetal  parts  in  the  placenta  is  very  slight,  the 
fcetal  villi  lieing  simply  withdrawn  from  the  maternal  crypts ;  the 
separation  in  them  cannot  be  termed  traumatic,  for  it  involves 
no  laceration  of  tissues.  In  the  mammals,  however,  with  a  caducous 
or  deciduate  placenta,  and  more  especially  in  the  human  female, 
the  maternal  and  ftetal  portions  of  the  placenta  are  intimately 
interwoven,  and  almost  fused  together;  a  real  tearing  apart  takes 
place  in  laliour,  with  a  blood  loss  varying  considerably  in  amount 
but  of  constant  occurrence.  As  a  result  of  this  separation,  an 
exposed  surface  (placental  site)  of  at  least  4^  by  -i  in.  is  left 
in  the  interior  of  the  uterus ;  this  is  the  maternal  side  of  the 
traumatism;  and  Nature  diminishes  as  much  as  possible  the 
consequent  risks  by  the  property  of  the  uterine  muscle  called 
retraction,  whereby  the  exposed  surface  is  lessened  in  extent.  The 
separation  of  the  placenta  takes  place  through  the  spongy  layer 
which  is  derived  from  the  maternal  decidua  serotina.  To  what 
extent  the  fcetal  portion  of  the  placenta  (the  villi)  is  exposed  in 
this  sm'face  of  separation  (placental  area)  is  uncertain,  but  doubtless 


38  ANTKNATAl.    I'A  TllOLOC'i'    AND    llVdlKNF. 

simu'  of  the  choiinnic  villi  loacli  down  as  far  as  the  sjiongy  layer; 
it  may  tlierel'ore  be  said  that  here  is  tlie  fa>tal  side  of  the  traumat- 
ism. At  the  same  time,  it  must  be  borne  in  mind  that  changes 
have  been  occurring  in  tiie  villi,  during  the  last  weeks  of  pregnancy, 
which  tend  to  obliterate  the  vessels,  and  so  lessen  the  risks  following 
the  sejjaration  (ha-morrhage  an<l  sei>tic  absorption).  As  stated  by 
Eden  {Jonrn.  Path,  and  JjactcrioL,  ]i.  4GG,  Jan.  1.S9G),  the  villi  which 
become  embedded  in  the  scrotina  "are  devascularised  and  function- 
less";  further  {ihid.,\\  268,  Dec.  1896),  the  same  author  has  found 
that  "the  fuctus  takes  decided  measures  to  cut  itself  off  from  its 
placenta  during  the  last  weeks  of  intrauterine  life."  It  is  therefore 
very  probable  that  by  natural  processes  the  separation  of  the  placenta 
is  prevented  from  bringing  much  risk  to  the  f<i-tus,  and  we  cannot 
look  upon  the  uterine  as]iect  of  the  placenta  as  an  exjiosed  fo4al 
surface;  but,  artificially,  the  obstetrician  ]»roduccs  an  exposed  surface 
when  he  cuts  the  cord,  although  he  diminishes  the  risks  resulting 
from  it  (h;emorrhage  and  septic  alisorption)  when  he  ligatures  it 
before  .section. 

It  is  evident,  then,  that  birtli  is  traumatic.  In  the  best  circum- 
stances, however,  liy  a  wonderful  series  of  precautiims,  the  dangers 
of  the  traumatism  are  reduced  to  a  minimum,  justifying  the  descrip- 
tion of  it  as  physiological.  It  is  physiology,  however,  which  very 
readily  passes  over  into  pathology;  for  both  the  pressure  effects  and 
the  separation  results  may  very  easily  set  up  morltid  changes  in 
the  ftctus,  or  bring  pathological  conditions  as  their  secpiehc.  These 
morbid  processes  will  be  descrilied  in  the  next  chapter. 

Physiological   Readjustment  at   Birth. 

Birth,  then,  is  the  more  or  less  traumatic  transition  from  the 
l)rotected  semiparasitic  life  of  tlie  foetus  to  the  more  exposed  and 
ultimately  independent  existence  of  the  infant ;  but  traumatism  is 
not  the  only  occurrence  in  the  physiology  of  this  neonatal  period  of 
life,  for  it  is  during  the  three  or  four  weeks  that  follow  birth  that  the 
organs  of  the  new-born  infant  take  uji  the  work  now  thrust  upon 
them,  and  formerly  performed  in  great  part  by  the  placenta.  It  is  a  time 
of  rcailjustment,  of  adaptation,  of  alteration,  and  of  metamorphosis. 

Hirth,  it  must  be  remendjcred,  does  not  mark  a  l)eginning,  but 
a  stage  in  life's  progress ;  at  any  rate,  it  marks  only  the  beginning 
of  a  stage — the  beginning  of  postnatal  life.  The  transition  is  abrujit, 
and  the  sm-roundings  are  very  unlike,  nevertheless  the  life  is  con- 
tinuous. The  more  perfect  and  complete  our  knowledge  of  the 
physiology  that  ])recedes  and  of  that  which  follows  birth  becomes,  the 
more  clearly  and  undeniably  this  ]irinci]ile  is  cstalilishcd.  There  are 
differences  between  the  life  of  the  fietus  and  that  of  the  new-born 
infant ;  but  by  means  of  a  marvellous  series  of  adaptive  mechanisms,  the 
life  that  is  before  liirth  becomes  continuous  with  the  life  that  is  after 
birth,  and  the  transition  is  accomi)lishcd  with  a  minimum  of  change  and 
with  but  a  ]iassing  dislocation  of  function.  Some  only  of  the  organs 
of  the  infant  are   tndv  liorn  at  birth,  in  the  sense  that  thev  be^in 


READJUSTMENT  AT   BIRTH  39 

then  for  the  first  tune  to  perform  the  special  functions  for  which  they 
are  intended ;  most  of  them  continue  to  functionate  in  postnatal  life 
in  nearly  the  same  way  as  was  foreshadowed  liy  their  antenatal 
activities,  in  some  instances  with  increase,  in  others  with  diminu- 
tion, and  in  yet  others  with  some  modification  of  the  special  activity ; 
some  few  of  the  organs  may  be  said  to  die  at  birth,  as  far  as  pliysio- 
logical  activity  peculiar  to  them  is  concerned.  To  this  complicated 
series  of  adaptive  processes  the  name  of  the  physiological  readjust- 
ment of  birth  may  be  given;  and  since  it  has  much  to  do  with  the 
peculiarities  of  the  pathrilogy  of  the  new-born  infant, it  demands  further 
cmisideration. 

The  adaptive  functional  changes  at  liirth  may  be  grouped  in  three 
classes  : — 

1.  Increase  or  commencement  of  function  I   ,-,        ,•,    ,• 

o    i>  1    i-f        <■  f       *•  -Quantitative. 

2.  Decrease  or  abolition  ot  function  | 

3.  Alteration  or  modification  of  function — Qualitative. 

There  is  much  that  is  yet  uncertain  aliout  the  functions  of  the  fcetal 
organs  and  tissues,  and  even  the  pliysiology  of  the  new-born  presents 
unsolved  proVilems,  so  that  what  follows  must  be  regarded  as  in  some 
degree  hypothetical  and  lialile  to  correction  with  advancing  know- 
ledge. 

The  abolition  of  the  functional  activity  of  the  placenta  is  the  most 
outstanding  of  the  liirth  changes,  and  all  the  other  alterations  and 
modifications  are  directly  or  indirectly  the  results  of  it.  At  the  end 
the  transition  is  sudden,  and  tlie  placental  economy  ceases,  as  it  were, 
with  the  tying  of  the  umbilical  cord :  but  it  is  well  to  remember  that 
there  has  been  a  period  of  a  few  weeks  during  which  vascular  changes 
have  been  occurring  in  the  placenta  which  have  slowly  been  cutting 
it  off  from  the  foetus.  The  placenta,  so  to  speak,  has  not  been 
abolished  without  warning ;  herein  possibly  lies  one  of  the  many 
reasons  why  premature  delivery  is  borne  so  badly  by  the  fcetus,  the 
preparatory  changes  in  the  after-birth  not  having  had  time  for  their 
completion.  Xow,  the  cutting  off  of  the  placenta,  with  the  consequent 
stoppage  of  all  the  functions  performed  by  it  in  intrauterine  life, 
necessarily  entails  the  awakening  to  functional  activity  or  increased 
activity  of  intracorporeal  organs  belonging  to  the  new-liorn  infant ; 
and  if  all  the  functions  that  are  performed  by  the  placenta  were 
definitely  known,  then  it  miglit  be  possible  to  distribute  and  rearrange 
these  functions  among  the  infantile  organs.  In  the  meantime,  there 
are  many  lacuiue  in  our  knowledge,  and  it  is  not,  for  instance,  clearly 
made  out  to  what  extent  bio-chemical  changes  actually  take  place  in 
the  placenta,  and  to  what  extent  that  organ  acts  simply  as  a  means  of 
conveying  the  results  of  maternal  bio-chemical  changes  to  the  foetus. 
All  that  can  be  said  with  any  assurance  is  that  the  cessation  of 
l)lacental  activity  synchroni.ses  with  the  commencement  of  pulmonary 
respiration,  and  with  the  increased  action  of  several  other  organs, 
such  as  the  kidneys  and  stomach. 

The  first  group  of  tlie  adaptive  functional  changes  at  birth  includes 
those  characterised  by  increase  or  commencement  of  function.  The 
luiiffs    at    once  sugcjest   themselves  as    orcrans    wliich   commence  to 


40  ANTKNATAI-    rA'lIlOI.OGY   AND    IIYdlEXE 

functionate  at  birth.  Very  evidently  and  almost  eonstantly  the 
infant  gives  a  cry  and  begins  to  breathe  as  soon  as  he  is  fully  expelled 
from  the  maternal  jjassages,  and  before  the  complete  severance  from 
the  ])lacenta  has  taken  jilace ;  in  this  respect,  the  commencement  of 
pulmonary  nspiralion  marks  the  begiiniing  of  postnatal  life.  Even 
this  change,  however,  is  less  sudden  than  it  apjiears,  for  in  fietal  life 
it  has  been  found  that  regular  movements  of  the  thora.x  are  taking 
place,  which,  although  they  do  not  of  course  result  in  the  admission 
of  air  to  the  foi'tal  lungs,  may  yet  be  preparatory  to  the  awakening  of 
the  pulmonary  activity,  and  may  become  after  birth  the  movements 
of  respiration.  Further,  under  (piite exceptional  circumstances,  as  in 
face  cases  and  during  version,  especially  with  twins,  respiration  and 
even  audible  crying  may  take  place  while  the  child  is  still  in  the 
maternal  passages,  the  condition  necessary  for  this  preniature  activity 
of  the  pulmonary  organs  being  the  rupture  of  the  ftntal  membranes 
and  the  admission  of  air.  The  cause  of  the  first  respiration  is  still 
matter  of  discussion  (it  has  been  ascribed  to  the  action  of  the  cold  air 
upon  the  skin  of  the  child,  to  the  passage  of  blood  containing  carbonic 
acid  in  excess  to  the  medulla  on  account  of  the  stoppage  of  the  gaseous 
interchanges  in  the  placenta,  and  to  the  convenient  but  not  very 
luminous  alistraction,  "a  i)rimitive  law  of  nature  ") ;  but  its  etl'ect  is 
to  usher  in  the  adaptatioual  changes  of  birth,  being  indeed  itself  the 
first  and  most  important  member  of  the  series.  Auscultation  over  the 
chest  of  the  new-born  infant  elicits  the  presence  of  a  fine  crepitant 
nlle  which  indicates  the  opening  up  of  the  pulmonary  air  vesicles, 
and  is  evidence  that  the  child  is  beginning  to  do  for  himself  what  was 
])reviously  done  for  him  by  the  matei^nal  lungs.  For  some  little  time 
the  new  function  is  not  performed  with  that  completeness  and 
regularity  to  wliich  it  afterwards  attains,  but  it  immediately  draws  to 
the  lungs  an  increased  fiow  of  blood,  and  so  inaugurates  the  wonderful 
succession  of  circulatory  readjustments  which  follow  birth. 

Among  the  increased  activities  supervening  upon  birth  must  be 
reckoned  the  digestive  functions  of  the  salivary  glands  (at  least  of 
the  parotid),  and  stomach,  and  intestine,  and  the  excretory  function 
of  the  kidneys.  The  urinary  Idadder  of  the  new-born  contains  a 
small  quantity  of  lu'ine,  and  in  its  intestines  are  about  70  grnis. 
of  the  dark  green  liile-stained  material  to  which  the  name  of  meconium 
has  been  given,  and  which  consists  of  intestinal  secretions,  fat,  bile, 
epithelial  cells,  some  hairs,  and  epidermic  squames.  It  is  therefore 
clear  that  there  is  some  digestion  going  on  in  fa>tal  life,  and  some 
urinary  secretion,  even  if  it  be  denied  that  there  is  any  excretion. 
Gradually,  all  the  digestive  functions  come  into  play,  although  it  is 
some  time  before  the  jiancreas  is  etlective,  and  the  submaxillary  and 
sulilingual  glands  do  not  at  first  take  much  part  in  buccal  digestion. 
Another  organ  which  must  be  regarded  as  increasing  its  activity 
greatly  at  birth  is  the  brain,  but  it  even  shows  an  increase  and  not  a 
commencement  of  function  with  the  change  of  environment ;  for 
some  parts  of  the  great  afferent  tract  of  nerve  fibres  in  the  brain  are 
already  myelinated  when  birth  takes  jilace,  ami  it  is  known  that  only 
filires    which   have   been  conveying  imjiressions   show    myelination. 


READJUSTMENT   AT   BIRTH  41 

The  movements,  therefore,  which  the  fcL'tus  has  been  making  in 
utero  have  been  sending  impressions  to  the  receptive  centres  in  its 
cerebral  cortex  ;  in  the  new-born  infant  the  impression-sending  goes 
ou  apace,  and  the  consec^nent  myelination  extends  rapidly.  It  is, 
however,  quite  correct  to  say,  that  functionally  some  parts  of  the 
brain  commence  to  act,  are  born,  at  birth. 

An  instance  of  the  cessation  of  function  following  upon  birth  is 
found  in  the  vessels  connected  witli  the  umbilical  cord,  which  carry 
blood  to  and  from  the  placenta.  These  vessels,  including  the 
umbilical  vein  and  arteries  and  the  ductus  venosus,  soon  become 
obliterated  and  fuuctionless  ;  and  any  delay  in  their  closure  may 
lead  to  dangerous  consequences,  as  will  be  shown  immediately. 
Another  physiological  activity  which  diminishes,  is  growth.  No 
doubt,  the  new-born  infant  increases  in  weight  and  length  with 
wonderful  rapidit}' ;  but  it  is  none  the  less  true  that  the  postnatal 
rate  of  growth  is  small  compared  with  what  prevailed  in  utero,  and 
indeed  the  slackening  had  already  begun  to  show  itself  before  the 
infant  left  his  uterine  abode.  Organ  formation  has  practically 
ceased  before  birth,  and  only  slight  changes  in  the  shape  and 
relations  of  the  viscera  occur  after  it,  although,  of  course,  the 
osseous,  as  distinguished  from  the  cartilaginous  skeleton,  is  largely  a 
postnatal  formation. 

Certain  alterations  in  function,  qualitative  changes,  take  place  at 
or  soon  after  birth.  Through  the  gradual  closure  of  the  foramen 
ovale  and  ductus  arteriosus,  the  direction  of  tiie  blood  current  in  the 
heart  is  altered,  and  the  function  of  that  viscus  as  the  centre  of  a 
double  instead  of  an  almost  single  circulation  is  established  ;  no 
longer  a  mixed,  but  a  pure,  blood  goes  to  the  tissues  as  the  result  of 
this  change.  Another  organ  which,  no  doubt,  to  some  extent, 
modifies  its  functions  at  birth  is  the  liver;  the  portal  circulation 
gains  in  importance  with  the  commencement  of  more  active  gastric 
and  intestinal  digestion,  and  proliably  the  liver  takes  on  the  function 
of  storing  up  mineral  poisons,  a  duty  which  there  is  reason  to  believe 
was  previously  performed  by  the  placenta. 

There  are,  as  has  already  been  stated,  many  parts  of  this  series 
of  readjustment  and  adaptation  changes  of  birth  about  which  little 
is  definitely  known,  and  about  which  much  will  yet  be  learned 
by  careful  investigation.  How  long,  for  instance,  are  the  mammary 
glands  active  before  birth,  and  how  long  after  birth  does  their 
secretory  activity  continue  ?  Do  the  Graafian  follicles  in  the 
ovaries  rupture  before  birth ;  and  if  so,  is  this  period  of  activity 
followed  by  one  of  quiescence  until  puberty  ?  What  is  the  function 
of  the  thymus  gland  in  the  foetus,  and  does  it  continue  to  act  in 
the  same  or  in  a  different  way,  or  not  at  all,  in  the  new-born 
infant  ?  Does  the  thyroid  gland  act  as  a  regulator  of  metabolism 
and  growth  before  as  well  as  after  liirth,  or  is  this  duty  performed 
by  the  thymus  ?  What  exactly  are  the  functions  of  the  spleen 
and  suprarenal  capsules  before  birth,  and  are  these  modified  by 
liirth  ?  These  and  several  other  questions  call  for  an  answer  before 
the    whole    process    of    functional   readjustment    at    birth    can    be 


42  ANIl-.NAIAI.    l'A■|■ll()I.()(i^•    AM)    ll^(ilF,NE 

described  iu  all  its  delails.  It  may  be  udilrd  thai  the  spinal  cord 
is  jnobably  an  instance  of  an  organ  wliose  functional  activities  alter 
little  at  liiitli,  for  in  the  fa-tus  it  is  well  developed  and  active; 
and  it  is  in  the  cerebral  rather  tlian  in  the  sjiinal  part  of  the  nervous 
system  that  development  of  function  goes  on  postnatally. 

j\Iany  of  these  functional  alterations  at  birth,  possibly  all  of 
them,  are  accompanied  by  changes  in  structure  which  are  directly 
related  to  them,  or  which  may  be  only  synchronf)US  with  them.  For 
instance,  there  are  the  well-known  obliterative  clianges  in  the  blood 
vessels  connected  with  the  fictal  circulation,  and  the  closure  of  the 
conmmnication  between  the  right  and  left  auricles  of  the  heart ; 
there  are  changes  in  the  appearances  of  the  blood  and  in  the  composi- 
tion of  the  urine ;  there  is  the  extension  of  myelination  to  the  eti'erent 
nerve  fibres  in  the  higher  centres ;  there  is  tlie  desquamation  of  the 
cuticle ;  and  there  is  the  disappearance  of  the  ftetal  lobulation  of  the 
kidneys.  These  are  the  anatomical  readjustments  of  the  neonatal 
epoch.  Finally,  birth  is  followed  by  an  invasion  of  the  new-born 
organism  by  a  multitude  of  microbes,  and  tlieir  ett'ects  upon  the 
developing  functions  must  be  taken  into  account  in  attempting  to 
understand  this  most  interesting  part  of  the  earlier  period  of  post- 
natal life. 

Such,  then,  is  an  outline  of  the  physiology  of  birth,  and  of  the 
four  weeks  which  follow  birth  :  there  is  the  i)hysiological  traumatism 
of  birth,  characteristic  more  especially  of  the  intranatal  i)eriod ;  and 
there  is  the  physiological  readjn.stnient  at  and  after  birth,  commencing 
in  the  intranatal  period,  Init  extending  into  and  through  the  strictly 
neonatal  epoch.  As  will  be  seen  immediateh",  when  som.e  of  the 
individual  diseases  and  morliid  states  of  the  new-born  fall  to  be  con- 
sidered, these  pliA'siological  peculiarities  of  the  period  have  much  to 
do  with  the  peculiarities  of  the  pathology  of  the  period,  and  many 
things  that  are  difficult  to  understand  about  neonatal  morbid 
conditions  become  easy  of  explanation  when  regarded  in  the  light  of 
the  ]ihysiological  traumatism  of  birtli,  and  the  physiological  readjust- 
ment at  Ijirth ;  lint  all  the  peculiarities  are  not  explicable  liy  these 
two  factors,  either  acting  singly  or  working  in  combination.  There 
is  a  third  factor  which  plays  its  part  in  the  evolution  of  the  special 
character  of  neonatal  pathological  cliange ;  it  is  the  antenatal 
factor. 

The  Antenatal  Factor  in  Neonatal  Pathology. 

Not  only  does  the  physiology  of  birth  and  the  neonatal  period 
leave  its  distinctive  impress  upon  the  pathology  of  the  neonatal 
period,  but  the  pathology  of  antenatal  life  also  has  its  etlect  upon  the 
characters  of  the  diseases  and  disorders  of  the  new-born,  and  serves 
to  explain  some  phenomena  otherwi.se  most  obscure,  liirth,  let  it 
always  be  remembered,  is  not  the  beginning  of  life;  it  is  only  the 
beginning  of  a  stage  of  an  individual  life.  The  impress  of  nine 
months'  very  active  life,  intrauterine,  it  is  true,  l)ut  none  the  less 
vital,  is  already  on  the  infant  at  the  moment  of  birth.     Its  ett'ects, 


THE   ANTENATAL   FACTOR  43 

pathological  as  well  as  jiliysiological,  are  projected  into  neonatal  life, 
and  in  many  cases  constitute  the  missing  key  to  the  explanation  of 
the  special  characters  of  neonatal  disease.  Thus  morbid  conditions 
which  have  arisen  in  fictal  life,  such  as  fa'tal  peritonitis,  or  mal- 
formations which  have  originated  in  the  embyronic  or  germinal 
periods,  may,  by  their  projection  into  neonatal  life,  give  an  altogether 
peculiar  character  to  the  maladies  of  the  new  born. 

Many  instances  might  be  given  of  the  effect  of  the  antenatal 
factor  on  the  pathological  manifestations  of  the  neonatal  period  of 
life,  and  to  several  of  them  reference  will  be  made  in  the  following 
chapters,  which  deal  with  individual  neonatal  maladies ;  but  in  the 
meantime  it  will  sufhce  if  allusion  be  made  to  one.  Jaundice  in  the 
new-born  is  a  frequent  condition,  which  occurs  soon  after  birth.  It 
is  generally  one  of  the  results  of  the  readjustment  changes  which 
are  going  on  in  the  liver  and  blood  on  account  of  the  circulatory 
modifications  which  follow  the  replacement  of  the  placental  by  the 
pulmonary  respiration ;  it  is  in  these  cases  almost  physiological  in 
its  nature.  Sometimes,  however,  as  is  well  known,  the  jaundice  is 
of  a  much  more  persistent  type,  and  may  even  prove  fatal  within 
some  days  or  weeks  of  birth.  Under  these  circumstances  it  has 
sometimes  been  found  that  its  persistence  and  lethal  character  have 
been  due  to  conditions  developed  before  birth,  e.g.  congenital 
obliteration  of  the  bile  ducts,  or  antenatal  hepatitis.  The  jaundice 
then  indicates  a  truly  pathological  state  of  affairs,  and  is  further- 
more the  expression  of  morbid  states,  the  results  of  which  in  intra- 
uterine life  were  dormant ;  the  antenatal  factor  makes  its  influence 
felt  immediately  after  birth. 


CHAPTER   V 

Types  of  Xeonatal  Disease,  illustrating  the  Intru.sion  of  the  Antenatal  Factor: 
(1)  Intracranial  Traumatisms,  Cei^halhiiMuatonia  Xeonatoruin,  Farial 
Paralysis,  Fractures  of  the  Long  Bones,  Dislocations  ;  (2)  Intranatal 
Infections,  Ophthalmia  Neonatorum,  H;ematoma  of  the  Steruo-MastoiLl, 
Mastitis  Neonatonini. 

Ix  this  chapter  and  iu  the  next  is  described  a  series  of  tj'pes  of 
neonatal  diseases  and  disorders.  No  attempt  is  made  to  consider  all 
the  maladies  of  the  new-born,  for  that  would  entail  the 
description  of  a  very  large  number  of  diseases :  but  certain  tyjies 
are  selected  which  serve  to  illustrate  the  manner  in  wliicii 
the  physiological  traumatism  of  l)irth,  the  jihysiological  reail- 
justment  at  birth,  and  the  antenatal  factor,  tend  to  give  pecidiar 
characters  to  the  manifestations  of  disease  at  this  time  in  life.  Even 
the  types  that  have  lieeu  selected  are  not  each  described  iu  all 
their  details,  Ijut  only  in  those  which  have  special  reference  to  the 
effect  of  antenatal  influence,  for  this  work  is  concerned  primarily  with 
Antenatal  Patholog}-,  and  with  Neonatal  Pathology  only  in  so  far 
as  it  throws  light  upon  antenatal  morbid  changes.  At  the  same  time 
it  must  not  lie  forgotten  that  there  exists  a  very  close  connection 
between  the  pathnlogy  of  the  neonatal  and  that  of  the  antenatal 
jieridil. 

I.   Intranatal  Traumatisms. 

Cephalh.i:matuma  Neoxatokuji. 

Attention  has  been  already  drawn  to  the  fact  that  the  birth 
traumatism  is  the  cause  in  tlie  great  majority  of  cases  of  a  serous  nr 
scro-sanguinolent  swelling  upon  the  presenting  jiart  of  the  fcctal 
head;  to  this  swelhng  the  name  caput  succedaneum  is  commonly 
given.  When  labour  is  undidy  prolongetl,  or  when  the  natural 
traumatism  of  birth  is  reinforced  by  the  artificial  traumatism  of  tlie 
f<ircei)S,  there  may  be  a  very  considerable  effusion  of  blood  into  the 
scalp  tissues,  and  the  caput  becomes  a  hannatoma.  It  is  not,  how- 
ever, to  this  e.xaggerated  caput  or  birth-bruise  that  llie  name  cephal- 
hicmatoina  neonatorum  has  been  usually  given,  but  tn  a  swelling  which 
appears  two  or  three  days  after  birtii.  If  any  special  name  were 
given  to  the  caput,  it  might  lie  that  of  "  intranatal  cephalluvmatoma," 


CEPHALH.EMATOMA   NEONATOUUM  45 

for  it  is  produced  during  the  intranatal  period  uf  life;  the  term 
neonatal  cephalh;ematonia  would  then  be  restricted  to  the  swelling 
which  develops,  or  at  any  rate  is  recognised,  during  the  first  few 
days  of  neonatal  life  (Fig.  5). 

This  cephalluvmatoma  varies  in  size  from  a  hazel-nut  to  an  apple  ; 
is  more  or  less  rounded ;  is  situated  usually'  near  the  postero-superior 
angle  of  the  right  parietal  Ixine,  hut  nuiy  be  found  on  the  opposite 
siile,  or  more  rarely,  on  the  occipital,  temporal,  or  frontal  bones  ;  and 
is  generally  covered  by  normal  scalp.  It  is  tense  and  fluctuating,  is 
usually  unilateral,  biit  is  occasionally  Ijilateral,  and  may  even  l^e 
multiple ;  and  is  limited  exactly  by  the  sutures  and  fontanelles,  not 
crossing  from  one  bone  to  another.  Pressure  upon  it  does  not 
affect  its  size  or  cause  convulsions  or  coma.  From  its  first  appear- 
ance it  has  a  well-defined  margin,  and  later  there  is  a  distinct  hard 
rim  surrounding  its  base;  it  may  on  this  account  l)e  mistaken  for 
a  cranial  perforation,  with  herniation  of  brain  substance,  or  for  a 
circular  depressed  fracture,  but  the  absence  of  pulsation,  and  the 
detection  on  deep  palpation  of  the  underlying  cranial  bone,  ought 
to  prevent  this  error  being  made.  Its  existence  may  be  masked 
for  the  first  few  days  of  life  by  the  caput  succedaneum,  wliich  usually 
(iccupies  tlie  same  region  of  the  head ;  it  slowly  diiuinishes  in  size 
by  absorption,  save  in  the  cases  where  suppuration  occurs,  liut  it 
may  be  several  months  before  all  traces  of  it  disappear.  In  its 
pathology  it  consists  of  an  effusion  of  blood  between  the  peri- 
cranium and  the  cranial  lioue  underlying,  and  the  hard  rim  is  a  bony 
ring  which  forms  round  its  base  at  the  point  where  the  pericranium 
is  still  attached  to  the  bone.  The  effused  blood  may  be  found  in 
various  stages  of  absorption.  A  fracture  of  the  underlying  lione, 
with  haemorrhage  between  the  dura  mater  and  the  skull,  may  occur 
as  a  complication.  It  does  not  usually  endanger  the  life  of  the 
infant,  save  when  pus  forms ;  and  the  method  of  treatment  which 
has  hitherto  given  the  best  results  has  been  expectancy,  but  it  is 
questionable  whether  the  safety  conferred  by  aseptic  surgery  ought 
not  to  cause  us  to  i-econsider  the  whole  matter,  and  possibly  to  adopt 
more  radical  measures. 

In  attempting  to  explain  the  pathogenesis  of  the  sul)perieranial 
cephalhiematoma,  authors  have  had  recourse  to  the  intranatal  factor 
(birth-traumatism),  to  the  physiological  readjustment  at  birth,  and 
to  the  antenatal  factor.  It  is  a  rare  condition,  occurring  only  once 
in  two  hundred  or  two  hundred  and  fifty  labours,  therefore  it  cannot 
1)6  due  to  an  ordinary  circumstance  or  set  of  circumstances.  It  is 
more  common  with  male  than  with  female  infants,  and  in  primi- 
parous  rather  than  in  multiparous  mothers.  It  has  therefore  been 
confidently  ascribed  to  pressure  on  the  head  in  labour,  to  the  same 
causes  as  are  effective  in  producing  the  caput ;  but  it  has  been  found 
in  cases  in  which  the  head  did  not  present,  and  even  in  cases,  such 
as  that  reported  by  me  in  1893  (158),  where  the  labour  was  easy, 
rapid,  and  non-instrumental.  The  intranatal  or  traumatic  factor 
cannot  then  be  the  only  or  the  constant  cause  of  the  h;cmatoma,  and 
the  same  objection  applies  to  traumatism  apart  from  labour.     The 


4ii  ANll'.NAIAI.    I'ATllOLOCY    AM)    indlFAK 

cause  lias  lieen  lonkiMl  for  in  the  circiilaUny  cuiiilitifnis  wliicli  exist 
iniiueiliateJy  alter  Mrtli,  ami  which  are  the  result  of  the  change  to 
ail  extrauterine  eiiviroiiiueiit ;  and  the  hrittleiiess  of  the  lilood 
vessels,  and  the  ease  with  which  the  pericranium  can  he  sejiarated 
from  the  underlying  bone  in  the  new-liorii  infant,  have  been  lirought 
forward  as  at  least  ])redisposiii<^  causes.  These  exiilanations,  how- 
ever, all  fail  to  account  for  the  rarity  of  its  occurrence,  and  it  is 
found  necessary  ti)  look  to  antenatal  conditions.  Several  have  been 
suggested ;  but  reference  need  only  be  made  to  that  with  which 
Fere's  name  has  been  associated  (Mcv.  mens,  de  med.  et  dc  chir.,  iv. 
112,  1880).  He  found  that  at  the  site  of  predilection  of  the 
cephalhtematoma,  the  postero-superior  angle  of  the  right  parietal 
bone,  there  were  occasionally  seen  fissures  running  in  the  bone  in 
a  radiate  manner,  one  towards  the  sagittal  suture,  another  towards 
the  lambdoidal.  The  sagittal  fissure  sometimes  united  with  a 
similar  one  on  the  opposite  side  to  form  the  fontanelle  of 
(lerdy.  To  this  arrest  of  development,  as  shown  by  defective 
ossification  in  this  region  {obclion),  Fere  looked  for  an  explana- 
tion of  the  pathogenesis  of  sulipericranial  cephalhaniatoma.  Even 
slight  pressure  on  the  part  of  the  head  which  shows  this  anomaly 
will  cause  extension  of  these  fissures,  and  rupture  of  the  small 
blood  vessels  which  cross  them;  effusion  of  blood  will  quickly 
take  place  under  the  pericranium,  which  is  at  this  point  easily 
separable  from  the  underlying  bone.  In  this  instance,  therefore,  the 
traumatism  of  birth  is  not  in  itself  sufficient  to  account  for  the 
neonatal  morliid  condition,  neither  does  the  physiological  readjust- 
ment at  birth  form  a  complete  explanation  ;  the  antenatal  factor  has 
to  be  invoked,  and  is  found  in  arrested  development  or  delayed 
ossification  of  the  region  ohclion. 

Facial  1'aralysis  of  the  Xew-ISokx. 

It  is  not  unconinion  to  find  infants  who  have  l)een  extracted  by 
means  of  the  forceps  showing  a  transitory  form  of  facial  hemiplegia, 
or  "  facial  paralysis  of  the  new-born."  When  the  child  cries,  or  wiien 
it  is  at  the  breast,  the  unilateral  deformity  of  the  face,  due  to  the 
paralysis  of  one  of  the  facial  or  seventh  nerves,  becomes  very  notice- 
able :  the  lines  on  the  paralysed  side  are  obliterated  and  the  eye 
cannot  be  closed  (Fig.  5),  the  angle  of  the  mouth  is  drawn  to  the 
opposite  or  sound  side,  and  the  lines  are  there  deepened.  The  infant 
is  suffering  from  the  peripheral  form  of  facial  jiaralysis,  due  in  the 
great  majority  of  cases  to  jiressure  of  one  of  the  blades  of  the  forceps 
upon  the  seventh  nerve  at  the  point  where  it  emerges  from  the  stylo- 
mastoid foramen,  or  where  it  breaks  up  into  its  branches  in  front  of 
the  ear ;  the  nerve  is  specially  liable  to  injury,  on  account  of  the 
absence  of  the  mastoid  apophysis,  and  the  small  degree  of  develop- 
ment of  the  auditory  meatus  at  this  time  of  life.  In  most  cases  the 
]iaralysis  gradunlly  jiasses  oft',  from  two  days  to  six  weeks  being  the 
time  necessary  for  its  comiilete  disajipearance.  Generally,  there  is 
the  distinct  history  of  forceps  application  to  account  for  the  paralysis  ; 


or   THE 

UMVE;^SITy 


NEONATAL   FACIAL   PARALYSIS 


47 


hut  ill  a  few  instances  it  would  seem  that  the  i^ressure  upon  tlie  nerve 
has  heen  caused  hy  a  projection  in  the  maternal  pelvis  (promontory 
of  sacrum  or  ischial  spine),  or  by  a  tumour.  Sometimes,  as  in  a  case 
about  which  I  was  consulted  l>y  Dr.  Dickson,  of  Lochgelly,  in  1899, 
the  long  persistence  of  the  j)aralytic  condition  throws  doubt  npon  the 
peripheral  nature  and  traumatic  origin  of  the  palsy.  Under  these 
circumstances,  it  is  reasonable  to  turn  from  an  intranatal  to  an  ante- 
natal mode  of  origin  of  the  nerve  lesion.  It  may  then  be  due  to  a  lesion 
in  the  facial  nuclei  in  the  pons,  or  in  the  fibres  connecting  them  with 
the  cortical  centres  ;  but,  of  coiu'se,  even  this  central  or  cerebral 
form  may  be  of  intranatal  origin,  although  it  is  unlikely.  The 
instance  of   unilateral   facial   paralysis    reported  by  M.   Bernhardt 


(Xcu7-ol.  CciitrcdhJ.,  xiii.  1,  1894),  in  a  man  of  24  years  of  age, 
was  probably  of  this  central  type ;  it  had  been  first  noticed 
when  the  patient  was  a  fortnight  old,  and  the  birth  had  been 
non-instrumental.  Another  instance  of  persisting  paralysis  of 
congenital  origin  in  a  man  of  40  has  been  recorded  by  Mr. 
•Tonathan  Hutchinson  {Arch.  Surg.,  xi.  20,  1900).  In  the  central 
type  the  paralysis  is  seldom  so  complete  as  in  the  peripheral, 
and  there  usually  is,  for  example,  power  to  close  the  eye ;  by 
this  means  it  may  bie  possible  to  diagnose  Itetween  the  cases  of  peri- 
pheral and  intranatal  paralysis  and  those  of  the  central  and  probably 
antenatal  type — a  matter  of  very  considerable  importance,  when  it 
is  borne  in  mind  that  the  former  have  a  good  prognosis,  while  the 
latter  are  usually  incurable.  But  facial  paralysis  of  the  new-born 
may  be  both  peripheral  and  antenatal,  and  it  is  then  due  to  some 


48  ANll'.NAI'Al.    l'AriI()I,()(;V    AM)    IIY(;iKNK 

uialtoniiatiiiu  (ir  defeclive  duvulciimu'iit  uf  the  muscles  suj)]ilifil  liy 
the  seventh  nerve.  Tliis  seems  t"  have  heen  the  cause  of  the 
paralysis  in  tlie  two  brothers  descriljed  hy  11.  M.  Thomas  {Journ. 
Xerr.  and  Mcnt.  JJis.,  xxv.  .')71,  1898);  in  this,  an  instance  of  the 
family  type,  there  was  antenatal  absence  of  some  of  the  facial 
muscles.  It  ought  to  be  added  that  the  nature  of  the  antenatal 
lesion  in  the  central  form  of  facial  paralysis  of  the  new-born  lias  not 
yet  been  determined ;  but  iiejl  {Ccntrlbl.  f.  Gymik.,  xx.  634,  1896) 
has  described  a  ca.se  of  tlie  peripheral  form  of  antenatal  origin  in 
whicli  he  suggests  that  pressure  ui)()n  the  cheek  by  an  anmiotic  band 
was  the  active  cause  of  the  defective  development  of  the  seveiitli  nerve. 
The  relation  of  facial  paralysis  of  the  new-lioru  to  the  intranatal  (trau- 
matic) and  antenatal  factors  may  thus  be  summarised  :  the  peripheral 
form,  usually  complete,  is  nearly  alwaj's  due  to  intranatal  ])ressure  from 
the  forceps  or  maternal  pelvic  walls,  and  it  is  then  (puckly  recovered 
from ;  but  it  is  occasionally  due  to  antenatal  causes,  one  of  which 
may  be  amniotic  pressure,  and  is  then  much  le.ss  amenable  to  treat- 
ment ;  the  less  complete  central  form,  on  the  other  hand,  is  probably 
rarely  due  to  traumatism  acting  upim  tlie  liead  in  lalxiur,  and  most 
often  to  oljscure  antenatal  clianges  in  the  cerebrum  or  pons,  and  it 
has  ahvays  a  more  unfavourable  prognosis. 

Fkactures  of  the  Long  P)Oxes  of  the  XEw-lior.x. 

The  common  cause  of  the  fractures  of  tlie  long  hemes  wliicli  may 
l)e  met  with  at  birth  is  the  traumatism  of  an  abnormal  lalmur,  and 
more  especially  of  a  confinement  which  is  terminated  artiticially  liy 
version.  Further,  the  new^-born  infant,  like  the  child  or  adult,  may 
suffer  from  fractures  which  are  the  result  of  direct  and  considerable 
violence.  In  l)oth  cases,  the  incompletely  developed  state  of  the 
skeleton  will  predispose  to  the  occurrence  of  separation  of  the 
epiphysis  of  the  long  bones  rather  than  to  actual  solution  of  con- 
tinuity of  the  diaphysis.  Such  fractures  and  sejiaratious  usually 
heal  quickly,  if  recognised  and  treated  at  the  time  of  their  occur- 
rence. There  are,  however,  other  cases,  in  which,  either  at  birth 
or  soon  thereafter,  fractures  occur  either  subsequent  to  very  little 
traiuuatism,  or  without  the  history  of  any  injury  at  all.  In  such 
instances  it  becomes  necessary  to  postulate  the  existence  of  ante- 
natal fragility  of  the  bones.  The  extraction  of  the  child  from  the 
maternal  passages  or  some  slight  handling  of  it  afterwards  may 
still  be  the  determining  cause  of  the  fracture,  but  it  is  (juite 
evident  that  the  predisposing  factor  lies  in  defective  ossificatiem. 
Especially  is  tliis  clear  when  tlie  l)reak  occurs  one  or  two  days 
after  birth,  and  without  any  evident  cause.  Such  a  case  was 
brought  under  my  notice  in  May  1899,  by  Dr.  J.  S.  Fowler.  The 
child  was  apparently  quite  healthy  when  born :  it  was  an  ordinary 
head  presentation,  and  no  interference  was  required.  Four  daj'S 
later  it  began  to  cry,  and  cried  all  night,  and  in  the  morning  a  great 
swelling  of  the  left  thigli  was  noticed.  There  was  a  distinct  fracture 
in  the  middle  of  llic  femur,  not  near  the  epiphysis.    The  break  mended 


NEONATAL   DISLOCATIONS  49 

well,  but  with  a  large  amount  of  callus.  There  was  no  historj'  of  any 
injury ;  there  was  no  enlargement  of  any  of  the  epiphyses  ;  the  limbs 
were  well  formed  ;  and  the  child  showed  no  signs  of  prematurity.  It 
was  significant,  however,  that  the  cranial  bones  exhibited  very  defect- 
ive ossification  ;  although  there  was  no  increase  in  the  size  of  the  head, 
nor  any  sign  of  abnormally  high  intracranial  pressure,  yet  the  state 
of  the  bones  was  exactly  like  that  met  with  in  hydrocephalus.  Ante- 
natal fragility  seems  the  only  possible  explanation  of  the  fracture  in 
this  case.  It  is  not  unlikely  that  it  may  have  been  an  instance, 
although  not  a  very  marked  one,  of  osteogenesis  imperfecta,  or  osteo- 
psathyrosis (8) :  in  such  cases,  a  striking  example  of  which  has  been 
recorded  by  J.  P.  Crozer  Griffith  (Am.  J.  Med.  Sc,  cxiii.  426,  1897), 
fractures  of  the  long  liones  begin  to  occur  a  few  ho\xrs  or  days  after 
birth,  without  evident  and  sufficient  cause ;  they  continue  to  occur 
at  intervals  during  infancy  (Griffith's  patient  developed  seventeen 
of  them  in  his  first  two  years),  and  even  during  childhood  and 
adult  life,  and  they  usually  unite  very  C[uickly.  Syj)hilis,  nervous 
diseases,  and  rickets  can  generally  be  exclucled  from  the  list  of 
possible  causes;  and  there  is  much  doulit  as  to  the  osteomalacic 
nature  of  the  fractures.  One  remarkable  fact  has  been  clearly 
proved :  the  tendency  to  be  affected  with  numerous  fractures  is  often 
transmitted  by  direct  heredity ;  and  even  when  this  is  not  the  case, 
family  predisposition  can  be  distinctly  recognised — a  fact  which 
certainly  points  to  an  antenatal  mode  of  origin.  It  may  therefore 
he  regarded  as  certain  that  all  the  fractures  that  are  met  with 
during  the  neonatal  period  of  life  are  not  the  result  of  birth- 
traumatism,  or  of  injury  received  after  birth,  even  when  the 
skeleton  has  been  weakened  by  syphilis ;  some  are  due  to  an  ante- 
natal fragility,  so  great  in  degree  that  trifling  causes  lead  to  solution 
of  osseous  continuity. 

Dislocations  in  the  Xew-Borx  Infant. 

That  dislocations  of  various  joints  may  occur  as  the  result  of 
the  traumatism  of  birth,  and  more  particularly  of  artificially  aided 
birth,  is  an  obstetric  commonplace ;  possibly,  however,  it  is  an  ill- 
founded  commonplace.  Certain  it  is  that  by  far  the  most  common 
congenital  dislocation  is  that  of  the  hip ;  equally  certain  is  it  that 
in  the  great  majority  of  the  recorded  cases  the  child  suffering  from 
this  dislocation  has  been  Ijorn  after  a  labour,  non-instrumental  in 
character,  not  even  abnormally  prolonged,  in  which  also  the  head 
has  presented,  and  in  which,  consequently,  neither  blunt  hook  nor 
iibstetrician's  fingers  can  have  been  dragging  traumatically  upon 
the  infant's  hips.  Furthermore,  can  it  be  doubted  that  if  the 
dislocation  were  of  this  intranatal  kind,  that  it  would  be  easily 
possible  to  correct  it  ?  Yet  within  recent  years  there  is  probably 
no  subject  in  orthopedic  surgery  about  the  treatment  of  whicli 
more  has  been  written  of  a  controversial  kind  than  congenital  dis- 
location of  the  hip-joint.  Manifestly,  such  a  difference  of  opinion 
as  to  the  best  method  of  surgically  correcting  this  distortion 
4 


50  ANTENATAL    I'ATl  1(  )l.()( -N     AND    HVCill'.Nl-: 

betokeus  that  no  way  yet  devised  is  supremely  good ;  herein  lies  the 
suggestion  that  the  luxation  is  no  sinijile  displacement  of  perfectly 
adajited  articular  surfaces,  due  to  the  tractions  and  contractions  of 
labour.  The  ilislocatinn  itself  is  much  more  common  in  girls  than 
in  boys ;  it  may  be  bilateral  or  unilateral ;  it  is  commonly  not 
noticed  immediately  after  Ijirth,  but  only  later,  when  walking  is 
begun ;  and  it  is  noteworthy  that  in  about  25  per  cent,  of  the 
cases  there  is  heredity,  usually  on  the  mother's  side.  These  facts 
do  not  support  the  idea  of  olistetric  origin.  Indeed,  the  theory  that 
tlie  dislocation  is  entirely  due  to  intranatal  traumatism  may  l)e  .said 
at  the  present  time  to  be  alianiloned.  Of  the  theories  that  remain, 
all  look  to  an  antenatal  morljid  state  as  the  primary  cause.  Accord- 
ing to  one  view,  the  dislocation  is  due  to  external  violence,  applied 
to  the  mother's  abdomen  during  her  pregnancy;  according  to  another, 
it  is  the  prolonged  but  less  active  pressure  of  the  anniion  that  is 
tlie  pathogenic  factor.  An  intrauterine  destruction  of  the  tissues 
of  the  joint  is  the  leading  feature  in  a  third  hypothesis:  yet  another 
regards  all  the  changes  as  due  to  a  priiuar}-  alteration  of  the  fa-tal 
nervous  system,  causing  either  retraction  or  paralysis  of  the  peri- 
articular muscles.  These  are  theories  ])ased  upon  fwtal  pathologj"; 
but  embryonic  morl)id  changes  have  also  been  invoked,  and  several 
forms  of  arrested  development  of  the  acetaliulum  and  surrounding 
parts  have  been  adduced  in  explanation.  In  their  diversity  these 
theories  have  it  in  common  that  they  look  to  a  time  before  the 
Ijirth-traiunatism  for  the  causal  factor :  in  this  at  least  they  agree. 
Not  less  diverse  have  lieen  the  recommendations  for  treatment. 
According  to  one  suggestion,  which  has  at  least  the  merit  of 
age,  the  dislocation  is  to  be  treated  by  traction,  by  fixation,  by  pro- 
tection— "  for  eight  or  ten  hours  out  of  the  twenty-four  the  children 
lie  in  an  apparatus,  holding  the  leg  extended,  abducted,  and  rotated 
outwards " — and  this  is  to  be  carried  on  for  years ;  truly  a  weary 
prospect,  even  when  it  is  added  that  for  the  rest  of  the  twenty- 
fciur  hours  of  each  day  "they  move  about  freely."  Corsets,  also, 
"  with  perineal  bands,"  to  press  down  upon  the  trochanters,  are 
said  to  be  "  much  in  favour  in  Germanj'."  If,  however,  the  patient 
be  older  than  three  or  four  years,  little  benefit  can  be  expecte<l 
from  the  mechanical  plan,  and,  consequently,  recourse  has  been  liad 
to  forcible  reposition  of  the  head  of  the  femur  into  the  acetabulum- — 
under  aniesthesia,  with  nnich  rotating  and  abducting  and  ficxing  and 
extending  of  the  limb.  This  method,  first  advocated  by  I'aci,  lately 
modified  and  elaljorated  by  Lorenz,  retpiires  for  its  complete  success 
the  existence  of  a  normal  acetabulum  and  a  normal  femoral  head ; 
but  Antenatal  Pathology  has  revealed  that  these  are  precisely 
the  conditions  which  do  not  exist.  Therefore,  at  best,  we  are  to 
hope  for  a  pseudo-arthrosis ;  that,  too,  only  after  prolonged  fixation, 
following  the  forcible  reduction.  Xeed  it  be  wondered  at  that  Hoffa 
has  advocated  operative  measures,  and  that  Lorenz  has  lieen  led  to 
tiie  same,  or  a  modified  plan  of  iiroccdure.  Their  methods  have,  at 
any  rate,  this  in  their  favour,  tliat  they  .seriously  attempt  to  deal 
with  the  ditliculties — HotVa  bv  cutting  into  tiie  acetaliulum,  enlarging 


OPHTHALMIA   NEONATORUM  51 

it,  for  it  is  generally  very  rudimentary,  with  the  wharp  spoon,  and 
replacing  the  head  of  the  femur  in  it ;  Lcjrenz  by  directing  jiis 
attention  also  to  the  capsular  ligament.  But  with  these  operative 
procedures  comes,  of  course,  the  risk  of  death ;  at  the  same  time,  it 
is  to  be  noted  that  in  good  hands  the  risk  is  small.  When  all  this  is 
taken  into  account,  is  it  surprising  that  a  recent  writer  (E.  W.  Lovett, 
"  Keating's  Cyclopaedia  of  the  Diseases  of  Children,"  Supplementary 
Vol.,  p.  988, 1899)  warns  his  readers  that "  it  is  a  time  of  transition  and 
general  distrust."  Antenatal  Pathology  nray  yet  do  much  to  remove 
this  distrust  and  throw  light  upon  operative  measures.  Let  it,  in  the 
meantime,  lie  borne  in  mind  that  congenital  dislocation  of  the  hip 
has  an  antenatal  origin,  even  when  the  actual  separation  of  the 
articular  surfaces  takes  place  in  the  stress  of  the  labour-traumatism ; 
that  it  is  to  be  looked  upon  as  a  malformation  rather  than  as  a 
dislocation;  that  it  occurs  at  a  time  when  the  hip -joint  is  not 
fully  formed  and  Solidified  (the  relation  of  the  depth  of  the  cavity 
to  the  diameter  of  the  head  of  the  femur  at  birth  is  one  to  three, 
at  5  years  one  to  two);  that  it  ought  to  be  diagnosed  far  earlier 
in  life  than  it  commonly  is  (a  matter  which  involves  the  establish- 
ment of  the  diagnostic  signs  of  it  prior  to  the  commencement  of 
walking) ;  and  that  in  these  days  of  surgical  safety  it  is  well  worth 
considering  the  propriety  of  advising  immediate  opening  of  the 
defective  joint  rather  than  the  prolonged  methods  of  traction  and 
fixation,  and  the  like. 


II.  Intranatal  Infections. 

In  the  neonatal  morbid  conditions  to  which  reference  has  been 
made  (viz.  cephalhtematoma,  facial  paralysis,  fractures,  dislocations), 
it  has  lieen  shown  that  the  antenatal  exists  alongside  of  the  birth- 
traumatism  factor,  replaces  it  even  in  some  cases,  so  that  it  is  now 
recognised  that  an  intranatal  cause  is  not  of  so  much  etiologic 
importance  as  an  antenatal  one  ;  these  mrirbid  conditions  arise  not 
always  from  the  traumatism,  physiological  or  pathological,  of  labour ; 
but  sometimes,  at  least,  from  states  originating  before  birth.  There 
are,  however,  diseases  of  the  new-born  which  are  not  so  evidently 
predisposed  to  antenatally :  such  are,  for  instance,  some  of  the 
intranatal  infections.  Some  reference  may  be  made  here  to 
ophthalmia  neonatorum,  mastitis  neonatorum,  and  hematoma  of 
the  sterno-mastoid  muscle. 


QPHTH.'lLMIA   NeOXATOEU.M. 

Ophthalmia  neonatorum,  or  blennorrhcea  neonatorum,  once  the 
great,  or  one  of  the  great,  scourges  of  the  Lying  -  in  Hospitals 
— occurring  as  it  did  in  10,  12,  even  in  15  per  cent,  of  the  babies 
born  in  Maternities — is  now  but  a  shadow,  mercifully,  of  its  former 
malignant  self.  It  is  known,  and  has  for  some  twenty  years  been 
known,  to  be  due  to  the  entrance  of  the  gonococcus  into  the  con- 


52  ANII'.NATAI.    I'ATllOLOd^'    AM)    HVCilKNK 

jiiiictiviil  sac  of  tlie  lu-w-lmni.  The  goiiococcus  was  hukiiiL;  in 
the  maternal  vagina,  tiie  mother  having  snfVereil  from  gonorrhcea, 
at  any  rate  from  a  "discharge"  of  some  kind  in  pregnancy;  and 
the  infant's  head,  having  been  detained  in  the  canal,  e.g.  on  the 
perineum,  for  ])erhaps  some  minutes,  had  come  in  contact  with  the 
gonorrhu^al  secretion  containing  the  gonococcus ;  the  result  was 
infection  of  the  mouth  or  nose  or  eyes  of  tlie  child,  unless,  as  even 
in  pre-antiseptic  days  sometimes  happened,  great  care  were  taken 
to  wasli  away  all  discharge  from  the  infant's  face.  A  great  scourge 
once  upon  a  time.  For  it  led  on  to  blindness,  through  such  inter- 
mediate stages  as  conjunctivitis,  recognisable  on  the  third  day  of 
life,  becoming  purulent  a  day  or  two  later,  corneal  ulceration, 
corneal  perforation,  dislocation  perhaps  (of  the  lens),  pyramidal 
cataract,  adherent  leueoma,  anterior  staphyloma,  panophtiialmilis, 
and  atrophy  of  the  Inilb.  There  were  many  morbid  possiliilities ; 
liut  the  end  was  too  often  the  same — blindness  for  the  individual, 
and  economic  loss  to  the  State.  Primarily  an  intranatal  infection, 
it  did  not,  unfortunately,  remain  so,  for,  secondarily,  it  Ijecame  a 
neonatal  one  ;  the  discharge  from  the  one  eye  trickled  over  the 
liridge  of  the  nose  and  infected  the  other,  or  was  carried  by  the 
midwife  to  the  e^yes  of  another  child,  or  got  into  the  eyes  of 
the  nurse  or  doctor  treating  the  case.  The  first  woman  graduate 
in  medicine  lost  the  sight  of  one  eye  through  infection  from  a 
new-born  infant  suffering  from  ophthalmia,  whose  eyes  she  was 
syringing  (130).  Now  this  disease  is  happily  in  process  of  abolition, 
"almost  expelled  from  our  Maternities";  almost,  but  not  entirely, 
as  the  following  case  shows.  A  young  woman,  pregnant  for  the 
first  time,  and  at  about  the  eighth  month,  was  admitted  to  tlie 
Edinburgh  Maternity  in  August  1900,  sulfering  from  unilateral 
Bartholinitis,  gonorrhceal  in  origin ;  was  operated  on  with  all  care : 
and  soon  thereafter  was  discharged  till  labour  super\-ened.  She 
returned  for  her  confinement  in  September,  when  she  was  seen  by 
me ;  during  lier  labour  all  the  approved  prophylactic  measures 
(to  be  immediately  referred  to)  were  adoi)ted :  ne\'erthele.ss,  two 
or  three  days  after  birth,  the  infant  developed  signs  of  gonorrlupal 
conjunctivitis  in  the  right  eye.  Under  treatment  the  infiammatiun 
ran  a  comparatively  mild  course,  and  the  left  eye  was  scarcely 
affected  at  all.  There  was  no  other  case  in  the  Hosiiital.  The 
treatment  necessary  to  prevent  such  cases  has  passed  through  three 
stages,  if  we  regard  it  from  the  standjioint  of  the  time  when  it  is 
a]>])lie(l.  It  was  first  neonatal,  when  obstetricians  took  pains  to 
cleanse  the  face  and  eyes  of  the  new-l)orn.  Afterwards  it  became 
intranatal,  when  Crede,  and  those  who  adopted  his  methods,  began 
to  apply  to  the  eyes  of  the  infant,  l)efore  the  section  of  the  cord, 
a  drop  or  two  of  a  2  per  cent,  solution  of  nitrate  of  silver,  and 
to  use  corrosive  sulilimate  vaginal  injections  during  labour,  for  the 
purpose  of  disinfecting  the  maternal  passages.  It  has  now  to 
some  extent  become  antenatal,  for  it  is  beginning  to  Ije  recognised 
to  be  desirable  to  c(mimence  the  vaginal  disinfection  before  the 
supervention  of  parturition.      It  is  no  longer  thought  to  lie  necessary 


H.EMATOMA   OF   STERNO-MASTOIl)  53 

to  use  nitrate  of  silver  solution  us  a  prophylactic,  for  it  has  been 
founil  that  iusufflatiou  of  iodoform  powder  into  the  new-born's  eyes 
does  as  well ;  even  a  few  drops  of  boiled  water,  say  some  teachers, 
will  serve.  It  is  to  be  concluded,  therefore,  that  during  all  the 
years  when  prophylaxis  was  not  yet  thought  of  in  the  manage- 
ment of  this  disease,  thousands  of  infants  suffered  from  ophthalmia, 
and  became,  in  many  cases,  blind  and  burdensome  to  the  community, 
through  the  absence  of  a  few  drops  of  a  2  per  cent,  solution  of 
nitrate  of  silver,  or  of  pure  water,  applied  to  the  right  place,  at 
the  right  thne.  But,  and  herein  lies  the  antenatal  factor  in 
this  apparently  entirely  intranatal  matter,  in  some  instances  there 
is  evidence  to  show  that  the  eyes  have  been  infected  before  the 
passage  of  the  child  through  the  vagina,  for  the  eyes  may  show  at, 
or  a  few  hours  after  liirth,  changes  which  jjoint  to  the  second  stage 
of  the  ophthalmia.  This,  however,  is  a  subject  to  which  reference 
will  again  be  made  in  dealing  with  intrauterine  infection.  Let  it 
be  understood  that  it  is  not  always  necessary  that  it  be  gonococcic 
infection  that  produces  conjunctivitis  neonatorum ;  neither  is  it  the 
conjunctival  membrane  alone  that  is  ati'ected;  for  Bond  (Virginia 
Med.  Scini-Monflily,  xxi.,  1074,  1895)  has  reported  a  case  in  which 
the  eyes,  umbilicus,  vuh'a,  and  skin  glands  of  a  new-born  infant  all 
seem  to  have  been  infected  by  septic  matter  from  an  old  lacerated 
cervix  uteri  during  labour. 


H.EMATOMA   OF   THE    StERNO-MaSTOID   MuSCLE   IN 

THE  New-Born. 

The  occurrence  of  an  extravasation  of  blood  into  the  substance  of 
the  sterno-mastoid  muscle  has  an  importance  which  is  projected 
beyond  the  neonatal  period  of  life ;  for  it  is  currently,  and  it  may 
be  correctly,  regarded  as  one  of  the  causes  of  congenital  torticollis : 
and  that  unfortunate  condition  is  often  projected  onward  for  many 
years,  as,  it  is  said,  Alexander  the  Great  found,  who  was  well  able  to 
conquer  the  world,  but  had  a  wry  neck.  Occasionally  one  notes 
after  birth  a  swelling  ("  size  of  a  pigeon's  egg,"  "  shape  of  a  pencil ") 
in  one  or  other,  rarely  in  both  sterno-mastoids.  This  is  due  to  an 
effusion  of  blood  into  the  substance  of  the  muscle,  and  in  time  this 
gives  place  to  a  fibrous  thickening  of  it  following  upon  a  myositis  of 
a  parenchymatous  kind.  It  is  easy  also  to  believe  that  in  delayed 
or  instrumental  labours,  especially  in  those  in  which  the  breech  is 
born  first,  traction  on  the  neck  or  the  pressure  of  a  blade  of  the 
forceps  will  lead  to  such  lesions  in  the  cervical  muscles,  and  more 
particularly  in  the  sterno-cleido-mastoid.  But  then,  some  of  the 
labours  have  been  spontaneous  and  easy '  Under  these  circum- 
stances, ingenuity  has  alleged  that  attempts  at  respiration  have 
been  made  prematurely  while  the  infant's  neck  was  still  grasped 
in  the  maternal  passages,  and  that  these  muscles,  being  thus  put 
on  the  stretch,  have  been  ruptured.  This  notion  seems  at  any  rate 
to  be  accepted  by  Bronislaw  Kader  {Przcrjlad.  Chir.,  iv.  93,  1898),  in 


54  ANTKNATAL    I'ATHOLCXiV   AND    HYdll'.NK 

iiu  elaborate  contrihutiou  on  llie  subject  of  toi'tieollis  of  muscular 
origin,  how  valuable  one  is  not  quite  able  to  say,  for  it  appears 
in  the  Tolish  language,  with  but  a  short  summary  in  a  tongue  more 
generally  understood  in  Western  Euro]ie,  but  evidently  a  lengthy 
and  learned  paper.  To  explain  some  dilliculties,  it  has  been 
suggested  that  the  myositis  which  follows  the  injury  and  leads 
to  the  contraction  which  brings  about  the  torticollis,  is  of  infective 
origin,  and  Kader  (in  the  French  summary  of  his  article)  is  reported 
as  believing  that  the  infection  is  rid  the  blood  from  the  alimentary 
canal.  But,  in  tracing  this  connection  between  the  birth-trauniatism 
and  hiematoma  of  the  sterno  -  mastoid,  and  again  between  it  and 
muscular  torticollis,  there  are  other  difficulties;  for  it  is  not  at  all 
certain  that  a  lueuiorrhage  into  a  muscle  will  lead  to  a  shortening  of 
that  muscle,  either  with  or  without  rupture  and  myositis.  Further, 
there  is  the  associated  cranial  asymmetry  to  be  accounted  for. 
It  seems  at  any  rate  as  reasonable  to  look  for  an  antenatal  as 
for  an  intranatal  or  neonatal  origin.  No  doubt  ha-matoma  of 
the  sterno-mastoid  occurs  as  the  result  of  a  labour  in  which  the 
breech  has  presented :  but  there  is  a  doubt  whether  it  leads  on 
to  muscular  torticollis,  and  it  is  certainly  a  possibility  that  the 
latter  may  be  due  to  intrauterine  causes,  such  as  pressure  (amniotic 
or  other),  which  distort  the  head  and  neck  of  the  fcetus.  One 
matter,  however,  we  need  be  in  no  manner  of  doubt  alxiut :  that 
it  is  wise  to  inspect  with  care  the  state  of  the  sterno-mastoids  in 
infants  born  as  breech  presentations,  or  after  instrumental  deliveries. 
If  the  h;ematoma  be  there,  then  let  there  be  massage  and  inunction  : 
it  will  be  well  to  relieve  somewhat  the  torticollis,  for,  after  all, 
that  is  of  more  importance  than  the  proving  or  disproving  of  a 
theory. 

M.\STiTis  Xeonatorum. 

Not  a  few  medical  men  are  surprised  once  in  a  while  to  observe 
that  the  breasts  of  a  new-born  infant  are  distended  with  a  milky 
Huid  ;  sometimes  some  of  them  send  to  a  convenient  medical  journal, 
which  has  a  column  of  replies  to  correspondents,  a  startled  imiuiry 
as  to  the  meaning  of  this  curious  phenomenon,  adding  occasiunally, 
to  make  it  more  curious,  that  it  was  a  male  and  not  a  female  infant 
that  showed  this  remarkable  mammary  activity.  And,  look  at  it  as 
we  like,  and  even  after  familiarity  with  it  has  lessened  its  strangeness, 
it  is  a  curious  phenomenon  ! — worthy  to  lie  put  alongside  the  occa- 
sional discharge  of  a  red  sanguinolent  fluid  from  the  vagina  during 
the  first  days  of  life,  "menstruation  of  the  new-born."  Both  have  a 
meaning,  doubtless,  but  a  meaning  yet  to  lie  found  out ;  and  only  to 
be  found  out  after  we  have  discovered  all  the  details  of  that  mar- 
vellous series  of  changes  known  as  the  "  jihysiological  readjustment 
at  birth."  Some  things  are  known,  or  at  least  guessed  at :  during 
fVetal  life  the  sebaceous  glands  are  active,  secreting  freely,  and 
helping  thus  to  make  up  the  vernix  caseosa,  "  cheesy  varnish,"  of 
the  infant's  skin  :  it  is  thought  that  the  mammarv  glands  have  been 


MASTITIS    NEONATORUM  55 

evolved  from  sebaceous  glauds,  for  in  the  secretion  of  both  there  is 
much  fat;  but  other  embryologists  are  of  opinion  that  they  are 
nioditied  sweat  glands,  an  opinion  which  Minot  regards  as  resting 
"  upon  strong  evidence " ;  the  neonatal  mammary  secretion  is 
undoubtedly  lacteal,  chemical  analyses  all  agree  about  this. 
Chemically  milk  then,  but  something  queer  about  it,  Hcxenmikli 
the  Germans  call  it.  The  human  new-born  is  not  peculiar  in  this 
lactescent  character,  but  shares  it  with  some  of  the  young  of  the  other 
mammals — the  witches,  presumably,  not  restricting  their  attentions 
to  him  alone  (!)  Is  it  possilile,  it  may  be  hazarded,  that  as  the  foetus 
from  its  semi-parasitism  shares  so  intimately  in  tlie  bio-cliemical 
changes  of  the  mother,  changes  which  terminate  for  her  in  the 
establishment  of  lactation,  so  even  after  birth  the  character  of  the 
chemistry  of  the  body  goes  on  at  first  along  similar  lines,  and  causes 
activity  of  the  mammary  glands  in  the  infant  also  ?  Whether  this 
be  so  or  not,  there  need  be  no  hesitation  in  taking  measures  io 
prevent  meddlesome  midwives  or  mothers  squeezing  the  breasts  of 
the  new-born,  with  the  notion  (most  erroneous)  that  they  are  in 
this  way  doing  the  infant  a  service — "  breaking  the  breast-strings," 
they  say,  perhaps  in  justification.  Truly  the  most  malicious  of  the 
witches  could  wish  for  nothing  else  than  this  squeezing  of  the 
secreting  mammary  glauds  of  the  new-born  to  "  Ijreak  the  breast- 
strings,"  leading,  as  it  not  uncommonly  does,  to  mastitis  neonatorum, 
mammary  alDScess,  cicatricial  contraction,  and  years  afterwards,  when 
the  infant,  if  a  girl,  has  become  a  mother,  to  lactational  ineptitude. 
It  is  said  that  some  medical  men  even  believe  in  this  squeezing  as  a 
prophylactic  against  mastitis  neonatorum,  a  belief  which  provokes 
from  Dr.  J.  Comby  ("  Traite  des  maladies  de  I'enfance,"  v.  258, 
1898)  the  indignant  protest,  "  C'est  a  cette  opinion  que  je  m'attaque." 
Surely  it  is  to  he  expected  that  glands  in  a  state  of  physiological 
activity,  if  subjected  to  pressure,  amounting  generally  to  traumatic 
pressure,  and  at  the  same  time  not  kept  aseptic,  will  readily  pass  on 
into  inflammation,  aljscess  formation,  and  cicatrisation.  Evidently, 
then,  mastitis  neonatorum  is  a  clearly  estaljlished  neonatal  condition. 
Possibly,  however,  both  the  traumatism  and  the  infection  may  in 
some  instances  be  intranatal,  as  in  a  delayed  labour  in  a  vaginal 
canal  infected  with  gonococci.  More  than  this,  there  is  some 
evidence  in  support  of  the  idea  that  antenatal  predisposing  factors 
may  be  at  work  in  some  instances.  Two  cases,  occurring  in  my 
practice  about  seven  and  six  j'ears  ago,  contain  to  my  mind 
suggestions  of  some  such  antenatal  predisposition.  In  one,  the 
infant,  a  first  child  and  a  female,  had  when  born  a  skin  as 
absolutely  free  from  any  trace  of  vernix  caseosa  as  it  is  possible 
to  imagine ;  so  striking  was  it,  that  both  my  attention  and  that 
of  the  nurse  were  drawn  to  it  at  once.  During  the  first  month  of 
life,  that  infant  had  a  very  severe  and  widespread  attack  of 
eczema  neonatorum,  for  which  no  apparent  cause  could  be  found : 
the  crusts  were  very  marked.  Little  more  than  a  year  afterwards, 
the  brother  of  this  infant  was  born  :  he  exhibited  the  same  remark- 
able ab.sence  of  the  vernix,  although  in  not  so  striking  a  way ;  he 


5G  ANTKNATAI,    I'A'II  lOl.OdV    AM)    IIVCIKNR 

also  developed  trouljlesomo  eczema  and  intertrigo :  and,  furtlier, 
line  I  if  his  lireasts  became  greatly  enlarged  ami  inllanied,  but 
fortunately  did  not  go  on  to  pus  formation.  It  is  reasonable  to 
ask  whether  in  these  two  infants,  born  of  the  same  mother,  the 
absence  of  the  vernix  caseosa  at  birth  had  any  relation  to  the 
after-development  of  the  eczema  and  the  mastitis  neonatorum. 
The  circumstances  are  at  anv  rate  suggestive. 


CHAPTEE   YI 

Types  of  Xeonatal  Disease,  illustrating  the  Intrusion  of  the  Antenatal  Factor 
(contd.) :  (3)  Keonatal  Infections,  Tetanus  Xeonatoruni,  Erysipelas 
Xeonatorum,  Sepsis  Xeonatorum,  Hannoglobinuria  Xeonatonun,  Om- 
phalorrhagia Neonatorum  ;  (4)  Disturbed  Xeonatal  Readjustments, 
Icterus  Xeonatorum,  Mehena  Xeonatorum,  Keratolysis  Xeonatorum, 
Pemphigus  Xeonatoruni,  Sclerema  Xeonatoruni,  Aspliyxia  Xeonatorum, 
Xeonatal  Heart  Disease  ;  Summary. 

The  new-born  is  lialile  ii(.)t  (jiily  to  morbid  conditions  arising 
from  the  traumatism  of  labour,  and  from  infection  during  labour 
(intranatal  traumatism  and  infection),  but  also  to  maladies 
which  originate  in  infection  after  birth,  and  in  disturbances 
or  arrests  of  the  physiological  readjustment  which  occurs  at 
this  transitional  time  (neonatal  infection  and  disturbed  readjust- 
ment). Into  these  neonatal  morbid  entities,  just  as  into  those 
described  in  the  previous  chapter,  the  antenatal  factor  occasion- 
ally, perhaps  frequently,  intrudes  itself.  It  may  be  profitable  to  note 
the  manner  of  the  intrusion. 

III.   Neonatal  Infection. 

Tetanus  Xeonatouum. 

The  "  Scourge  of  St.  Kilda  "  is  happily  no  longer  so  to  be  called, 
for  tetanus  neonatorum,  once  so  fatal  to  the  new-born  St.  Kildans 
as  to  justify  that  appellation,  has  been  shown  to  be  preventible,  and 
is  accordingly  now  prevented,  in  St.  Kilda,  at  least,  and  soon  it  will 
be  everywhere  else,  let  us  hope.  Truly  a  scourge  indeed,  once  upon  a 
time,  not  long  ago  either,  in  that  most  western  of  the  Western 
Heluides,  lying  "  fully  forty  miles  west  of  North  Uist,"  called  "  Isle 
of  Feathers,"  also  for  many  birds  thereon  and  few  human  beings 
(population  in  1841, 105,  but  much  less  now).  Up  to  the  year  189-1: 
it  seemed  likely  that  there  would  be  fewer  men  and  women  and  more 
birds  as  the  years  went  on,  for  the  babies  born  on  the  island, 
although  all  "proper  bairns"  up  to  the  age  of  two  or  three  days, 
generally  gave  up  sucking  on  the  fourth  or  fifth  day,  on  the  se\'enth 
"  clenched  their  gums  together,  so  that  it  was  impossible  to  get 
anything  down  their  throats,"  were  seized  with  convulsive  fits,  and, 
"  after  struggling  against  excessive  torments  till  their  strength  was 
exhausted,  died,"  most  often  on  the  eighth  day,  the  disease  thereby 


58  ANll'.NATAL    I'A  THOI.OCV    AND    lIVdlKNK 

getting  till'  name  of  the  "  eij,dit-(lay  sickness.''  Many  things  ahout 
tliis  sifkiK'ss  (if  St.  Kiltla  have  heen  leeently  told  to  the  nietlical 
woild  hy  Dr.  (r.  A.  Turner  {Glasgow  Med.  Jovrn.,  xliii.  161, 
1895),  to  whom  and  to  Dr.  W.  L.  Keid,  as  well  as  to  the  Eev. 
Angus  Fiddes,  the  islanders  are  much  beholden,  for  through 
their  eflbrts  a  mortality  of  at  one  time  nearly  80  per  cent,  of 
new-liorn  infants  ("the  disease  proved  fatal  to  eight  out  of  every 
ten  children  horn  alive")  has  been  reduced  to  notliing  or  nearly  so. 
Various  were  the  alleged  causes  of  this  terrible  malady.  Tliere  are 
many  birds  in  the  island,  one  a  "  particularly  oleaginous  bird,"  the 
fulmar  by  name,  found  in  no  other  place  in  the  United  Kingdom, 
and  greatly  used  by  the  inhabitants  for  food;  possibly  its  oil,  some 
said,  getting  into  the  milk  of  the  mother,  proved  too  strong  for  the 
new-l)oru  infant.  Others  have  found i'auses  in  deficient  ventilation 
of  the  huts,  in  exposure  of  the  infants  to  sudden  alternations  of 
heat  and  cold,  and  in  the  zinc  roofs  of  tlie  newer  houses,  which  did 
not  protect  the  innuites.  Some  suggested  mismanagement  of 
the  umbilical  cord,  although  others,  and  among  them  Sir  Arthur 
Mitchell,  were  satisfied  that  there  was  "  nothing  exceptional  in  the 
mode  of  dressing  the  umbilical  cord  to  account  for  the  results."  An 
antenatal  cause  was  looked  for  in  race  deterioration,  through  the 
intermarriages  which  have  of  necessity  been  common  in  so  sparsely 
popvdated  an  island ;  and  this  view  was  advanced  to  comljat  the 
theories  founded  upon  defective  hygiene,  and  careless  dressing  of  the 
cord.  Nevertheless,  it  is  now  abundantly  demonstrated  that  the 
management  of  the  cord  had  at  any  rate  much  to  do  with  the 
etiology  of  the  disease ;  for  since  the  midwifery  nurse  has  secured 
surgical  cleanliness  of  the  umbilical  region  by  cutting  tlie 
cord  with  a  pair  of  clean  scissors,  dusting  the  stump  with 
iodoform  powder,  and  dressing  it  with  iodoform  gauze  and 
sublimate  wool,  the  infants  of  St.  Kilda  have  been  ]iractically 
free  from  tetanus.  The  tetanus  bacillus  ("  jiin-headcd.  bristle- 
shaped"  in  sjiorulation),  although  doubtless  still  jiresent  on  the 
island,  does  not  any  longer  make  his  way  through  the  umbilical 
wound  into  the  bodies  of  the  new-borns.  Nasccntcs  morimur 
("  being  born  we  die ")  is  not  now  applicable  to  the  infants 
of  St  Kilda;  not  the  infant  but  the  epitaph  is  for  ever  buried,  not 
to  1)6  resuscitated  I  Along  with  freedom  from  the  daily  newspaper 
and  the  post,  and  almost  complete  freedom  from  the  tourist,  St. 
Kilda  enjoys  immunity,  after  long  years,  from  tetanus  neonatorum. 
In  other  parts  of  the  world,  however,  the  disease  still  lingers,  and 
sporadic  cases  occasionally  occur  both  in  cities  and  in  countr}' 
places;  the  aseptic  treatment  of  the  cord  and  navel  is  necessary 
to  eradicate  these  few  remaining  cases.  The  di.sease  is  tetanus, 
but  tetanus  modified  by  the  neonatal  state,  the  chief  modi- 
fication being  that  the  bacilli  gain  access  through  the  umbilical 
wound.  It  may  bo  that  some  infants  are  antenatally  jiredisposed  to 
this  invasion  on  account  of  cougeuital  weakness,  and  conseiiuent 
imperfect  closure  of  the  umbilical  avenue  of  entrance  at  the  time 
when  the  cord  drops  otl';  but  the  antenaUil  factor  is  not  prominent 


ERYSIPFXAS   NEONATORUM  59 

ill    this    neonatal    disease,    mir    likely    to    lie    unless  consauguiuous 
marriages  can  be  shown  to  be  of  etioldgii-al  importance. 

Erysipelas  Neonatorum. 

Trousseau,  in  his  remarkable  "  Cliniqiie  mi'dicale  de  I'Hotel-Dieu 
de  Paris "  (tome  i.  p.  174,  1865)  has  a  fine  chapter  on  erysipelas 
iieonatoruiu,  a  chapter  which  leaves  us  wishing,  after  its  perusal,  that 
the  author  had  given  us  more  from  his  pen  upon  this  and  other 
diseases  of  the  new-born.  In  it  he  describes,  with  wonderful  insight, 
the  malady,  nearly  constantly  fatal,  "  pres(|ue  fatalement  mortel," 
which  is  still  known  as  erysipelas  neonatorum,  "  erysipele  des 
nouveau-nes."  He  had  been  struck  by  the  fact  that  when  puerperal 
fever  prevailed  at  the  JMaternite,  many  of  the  uew-liorn  infants 
suH'ered  from  erysipelas,  ophthalmia,  and  peritonitis,  and  he  had 
called  all  these  morbid  manifestations  "'  puerperal,"  regarding  them 
as  essentially  the  same.  This  opinion  he  liad  freely  expressed 
twelve  or  fifteen  years  before  (in  1850  or  1853),  but  the  view  had 
not  got  outside  the  hospital  walls,  had  not  at  any  rate  been  made 
widely  known,  had  at  the  most  been  gliding  gliost-like  through  the 
pages  of  some  medical  journals  ("  se  glissant  silencieusement  dans 
les  colonnes  de  quelques  journaux  de  mcdeciiie ").  P.  Lorain  had, 
liowever,  brought  the  matter  prominently  forward  in  his  thesis,  "  Sur 
la,  fievre  puerperale  chez  la  feinme,  le  fo?tus,  et  le  nouveau-ne  " 
(I'aris,  1855).  He  had  absolutely  demonstrated,  with  facts  really 
incontrovertible,  the  association  of  septic  conditions  of  mother  and 
infant — thirty  infants  dying  from  peritonitis,  simple,  or  with 
erysipelas,  ten  of  the  mothers  had  died  with  the  same  lesions  as  the 
infants ;  fif tj-  women  whose  infants  had  died  from  peritonitis  had 
themselves  jjuerperal  affections,  but  had  recovered.  Solidarity  in 
pathology  had  thus  been  established  between  mother  and  infant. 
"  11  est  impossible  de  ne  pas  accepter  en  patliologie  la  solidaritc  qui 
unit  entre  les  meres  et  les  enfants,  le  tronc  et  la  branche  qui  en 
emane."  But  Trousseau  and  Lorain  did  more  for  the  elucidation  of 
erysipelas  neonatorum :  they  pointed  out  the  peculiarities  of  its 
symptomatology  and  the  gravity  of  its  prognosis  in  a  way  that  left 
little  for  later  writers  to  add.  The  infant's  umljilicus  is  the  common, 
almost  constant,  avenue  of  entrance  for  infection ;  it  is  a  wounded 
surface  like  the  interior  of  the  mother's  uterus ;  the  infant  then 
takes  erysi]>elas  by  the  umbilicus.  But  the  first  signs  of  the 
erysipelatous  change  are  to  be  seen,  not  immediately  round  the  navel, 
liut  near  the  symphysis,  the  infection  having  travelled  thither  along 
the  vessels  (hypogastric  arteries).  Slowly  the  disease  passes  to  the 
scrotum  (or  vulva),  then  to  the  thighs,  gluteal  regions,  and  legs,  and 
finally  to  other  parts.  There  is  bright  redness  of  the  skm,  with 
hardness  of  the  subjacent  tissues,  there  is  sometimes  oedema  also,  and 
bulliu  containing  yellowish  serum.  The  swelling  of  the  parts  may  be 
very  great,  and  may  be  followed  by  desquamation  of  the  cuticle. 
There  is  fever,  with  a  rapid,  small  pulse ;  tlie  breast  is  refused  ; 
collapse   follows,   and    death,   often    unexpected,    cliises    the    scene. 


00  ANTHNAl  Al.    I'A  I  I  lOl.OCV    AM)    IIVCIENK 

Uiicoiiiiiioii  ciiiinilicatiiju.s  are  gangrene  of  tlie  aljiloiuiiial  walls  and 
elsL'where,  phlebitis  uf  the  unil)ilical  vein,  witii  hejiatitis  and  jaiuidic-e, 
peritiinitis,  jiieurisy,  etc.  Trousseau  pointed  out  that  when  abscesses 
t'ornied  in  the  sulicutaueous  tissue,  recovery  sonielinies  (jccurred, 
which  very  seldom,  if  ever,  happened  under  other  circumstances. 
The  explanation  of  this  fact  has  been  furnished  lately  by  P.  J. 
Achalme  (Thcsi.t,  Paris,  1892).  He  fomid  that  the  streptococci  (the 
bacterial  cause  of  erysipelas)  were  present  in  great  numbers  iu  the 
connective  tissue  separating  the  lobules  of  fat  in  the  subcutane- 
ous tissue.  They  were  also  very  numerous  in  the  walls  of  the 
lymphatics.  Nowhere  was  there  any  trace  of  a  multiplication 
of  leucocytes;  nowhere  was  there  any  evidence  of  the  phagocytic 
defence,  of  the  leucocytic  reaction.  Herein  lies  the  e.xplanation  of 
the  extraordinary  gravity  of  erysipelas  neonatorum ;  it  may  not 
be  the  only  explanation,  neither  need  it  be  all  the  explanation,  but 
it  is  a  working  hypothesis  to  fotuul  an  explanation  upon.  When, 
however,  abscesses  form  in  the  subcutaneous  tissue,  there  is  evidence 
of  the  phagocytic  reaction,  albeit  of  a  tardy  or  delayed  kind  ("  reaction 
phagocytaire  tardive");  and  under  these  exceptional  circumstances 
the  patient  may  recover. 

Generally,  it  cannot  be  doubted,  the  streptococcic  invasion  takes 
place  at  or  soon  after  birth,  and  the  di.sease  is  to  be  reckoned  as  a  true 
neonatal  infection  ;  sometimes,  however,  it  may  be  supposed  to  have 
occurred  in  labour  (intranatal),  and  rarely  it  has  been  intrauterine 
(antenatal).  Of  the  antenatal  oases  more  must  he  said  in  another 
chapter.  There  is,  however,  another  antenatal  aspect  to  the 
question,  for  causes  existing  l)efore  birth  may  have  contributed  to 
weaken  the  tissues  of  the  umbilicus  and  its  vessels,  and  so  to  hinder 
the  sejjaration  of  the  cord  and  the  closure  of  the  arteries  and  vein, 
and  thus  to  predispose  to  the  onslaughts  of  the  streptococci.  At 
any  rate,  the  proper  treatment  of  erysipelas  neonatorum,  as  of  tetanus 
neonatorum,  is  prevention:  and  that,  in  a  word,  is  to  be  obtained  by 
aseptic  treatment  of  the  umbilical  cord.  When  the  separation  of  the 
cord  leaves  a  surface  from  which  a  catarrhal  discharge  ("  und)ilical 
lochia"  of  Lorain)  is  coming,  or  from  which  there  is  actual  sup- 
puration, then  the  time  for  prevention  is  past,  and  an  active 
treatment  with  nitrate  of  silver  solution  is  indicated.  If  erysipelas 
neonatorum  have  declared  itself,  then  moist  antiseptic  applii'ations 
may  be  made,  the  anti-streptococcic  serum  tried,  and  possibly  saline 
injections  used.  A  healtliy  antenatal  life,  terminating  not  pre- 
maturely, along  with  the  aseptic  management  of  the  cord,  at  and 
after  birth,  these  con.stitute  the  best  treatment  of  erysipelas 
neonatorum — a  "  wise  prophylaxis." 

Ski'sls  Xeonatoku.m. 

In  certain  cases,  when  the  umbilical  cord  separates,  tlie  umliilicus 
does  not  look  unhealthy,  but  stains  of  blood,  and  even  of  pus,  are 
seen  on  the  dressings,  and,  on  separating  the  edges  of  the  cicatrix, 
one  can  see  a   small  ulcer;   this   may  be   regarded  as   tlie  mildest 


SEPSIS   NEONATORUM  Gl 

form  of  sepsis,  and  requires  washing  with  huric  lotion,  and  dusting 
witli  iodoform  powder.  In  otlier  cases  the  ulcer  has  led  on  to  the 
formation  of  a  small  rounded  mass  or  granulation  (granuloma)  in 
the  position  of  the  umbilical  cicatrix ;  myxomatous  in  its  pathology, 
pale  red  in  its  colour,  of  the  size  of  a  pinhead  or  a  pea,  bleeding 
when  handled,  throwing  off  a  constant  watery  or  purulent  secretion, 
with  or  without  excoriation  of  the  surrounding  parts ;  the  little 
mass  calls  for  antiseptic  treatment,  for  it  indicates  that  septic 
germs  are  at  work  in  the  innbilical  cicatrix,  and  are  preventing 
normal  union  of  surfaces.  There  is  no  clear  line  of  demarcation 
between  such  cases  and  those  in  which  the  skin  margin  surrounding 
the  navel  has  become  involved ;  in  this  condition  of  periumbilical 
lymphangitis,  the  intlammation  tends  to  be  superficial,  and  is 
attended  liy  some  pain  and  redness,  but  is  not  productive  of  much 
systemic  disturbance.  When  the  periumbilical  cellular  tissue  is 
also  involved,  another  stage  of  septic  invasion  has  been  reached, 
and  omphalitis  is  present ;  the  local  symptoms  are  more  marked, 
and  systemic  disturbance  is  now  to  Ije  observed  ;  pus  forms,  and  there 
may  be  abscesses  in  the  umbilical  region,  with  resolution  after  rupture 
or  after  surgical  evacuation.  There  is  again  no  line  of  demarcation 
between  omphalitis  and  erysipelas  neonatorum  {rid  the  nmbilicus) 
such  as  has  just  been  described ;  both  are  due  to  an  invasion  of 
the  tissues  with  the  streptococcus  through  the  innbilical  wound. 
With  or  without  the  appearance  of  erysipelatous  changes,  the  septic 
series  of  umbilical  manifestations  may  progress  still  further,  and 
widespread  ulceration,  and  even  gangrene  of  the  tissues,  may  result, 
manifestations  which  fortunately  are  rare  nowadays.  There  are  ■ 
yet  other  possibilities  of  neonatal  gepsis  through  the  umbilical  avenue 
of  entrance :  the  arteries  or  vein  may  become  the  special  seat  of 
infection,  the  streptococci  or  staphylococci  setting  up  thrombo- 
arteritis,  or  periarteritis,  or  thrombo-phlebifis,  and  from  these  foci 
the  germs  may  be  carried  to  distant  parts  of  the  body.  In  such 
cases  the  umbilicus  and  the  tissues  in  its  immediate  neighboiu'hood 
may  remain  apparently  quite  healthy ;  at  any  rate,  a  ease  reported 
liy  L.  P.  Audion  (Bull,  et  mhn.  Soc.  anat.  de  Paris,  6.  s.  ii.  241, 
1900)  and  two  others  by  Pierre  Audion  (ibid.,  p.  291)  suggest 
this  conclusion.  In  one  of  these,  the  infant  of  an  albuminuric 
mother,  born  fifteen  days  before  term,  showed  nothing  abnormal 
at  the  fall  of  the  cord  stump  (no  discharge  or  secondary  haemorrhage) 
on  the  fifth  day  of  life.  The  undjilicus  was  apparently  healthy  and 
cicatrising,  yet  death  occurred  on  the  seventh  day,  the  infant  having 
lost  350  grms.  in  weight,  and  having  had  convulsions  prior  to 
his  decease.  The  autopsy  revealed  an  apparently  healthy  umbilicus ; 
lint  a  probe  covdd  be  passed  in  easily  and  deeply  in  the  direction 
of  the  umbilical  vein,  which  was  wide,  smooth,  white,  and  sur- 
rounded by  some  vascularity ;  there  was  no  unhealthy  appearance 
of  the  neighbouring  peritoneum ;  the  probe  passed  on  easily  by 
the  ductus  venosus  into  the  vena  cava.  There  was  also  a  per- 
sistence of  permeability  of  the  umbilical  arteries,  from  defect  of 
retraction.     The  cause  of  death  was  suppurative  cereliral  meningitis, 


G2  ANTKNATAI.    I'A  THOI.OC^     AND    HVCilKNK  ' 

affecting  the  right  lemiMiral,  jiaiietiil.  ami  occijiital  lolies,  with  super- 
ficial (pileiiia  (iver  the  fniTilal.  Stre]iti)e<)cci  were  found  in  the  ]iu.s. 
In  the  unihilical  vein  was  a  small  clot,  slightly  adherent  to  the 
interior.  In  the  other  two  cases  the  conditions  were  somewhat 
ilitlerent,  but  pointed  to  the  same  mechanism  of  ndcrobic  invasion. 
It  is  ]irobal>le  that  in  these  cases,  and  in  others  like  them,  there 
is  also  an  antenatal  factor  at  work  as  well  as  the  neonatal ;  the 
prematurity  of  tlie  infants  (they  were  all  under  weight)  may  pre- 
dispose to  an  arrest  in  the  process  of  closure  of  the  vessels  of 
the  uudjilieus,  and  so  jiermit  invasion  of  the  organism  by  germs 
passing  along  the  distinctively  ftetal  route.  It  will  thus  be  seen 
that  there  is  a  series  of  cases  of  sepsis  neonatorum,  varying  in  degree 
and  in  locality,  but  agreeing  in  the  mode  of  entrance  of  the  infection. 
They  may  be  grouped,  as  Finkelstein  {Jahrh.  f.  Kinderhlk.,  S.  o. 
Bd.  1.  560,  1900)  proposes,  in  three  divisions,  with  subdivisions, 
thus: — 

1.  Local  intluinniation  of  undiilical  wound. 

(a)  Surface    infection  =  pyorrha'a ;  with  infection  of  the 

adjoining  arterial  thromlii  =  bleuorrhcea  umbilici. 
(1))   Ulcerative  process  =  ulcus  umbilici. 

2.  Local  umbilical  disease,  with  infection  of  the  umbilical  ring 

and  adjoining  abdominal  wall  =  omphalitis  simplex,  absce- 
dens,  gangra-nosa,  ulcerosa. 

3.  Progressive  umbilical  diseases. 

{a)  Thromlw-phlebitis  and  periphlebitis  nmbilicalis. 

(6)  Thrombo-arteritis  =  supiiuration   of   the   thrombus    in 

the  whole  length  of  the  arteries. 
{c)   I'eriarteritis  =  lymphangitis  nmbilicalis. 

(rt)  Primary  process. 

(&)  Secondary  to  omphalitis  or  idcus. 
{d)  Phlegmone  nmbilicalis  interna  s.  pr;vi)eritonealis. 

In  the  preceding  paragraph  the  umbilicus  alone  has  lieen  con- 
sidered as  the  route  by  which  septic  infection  takes  place  in  the 
new-born  infant;  but  although  it  is  a  very  characteristic  route,  it 
is  not  the  only  one.  Abrasions  of  the  cuticle,  or  actual  wounds 
of  the  skin,  may  occur  in  labour,  or  after  birth,  and  through  this 
cutaneous  avenue  of  entrance  streptococci  and  staphylococci  may 
pass.  The  infant  may,  during  his  progress  through  the  pielvic  canals, 
make  premature  efforts  at  respiration,  and  draw  septic  vaginal 
discharge,  or  even  liquor  amnii,  into  his  lungs  or  stomach,  and 
so  lead  to  infection  of  these  organs.  The  conjunctival  membranes 
may  also  be  inoculated  with  septic  germs,  although,  as  has  been 
already  noted,  it  is  more  commonly  the  gonococcus  than  the  strepto- 
coccus that  gains  a  lodgment  there,  and  the  same  remark  applies 
to  the  genito-urinary  nuicous  membrane.  The  conditions  produced 
by  septic  invasion  along  these  different  routes  are  all  to  be  regarded 
as  forms  of  neonatal  sepsis;  they  arise,  some  of  tliem,  in  the  intra- 
natal, and  some  of  them  in  the  neonatal,  and  some  of  them  even  in 
the  antenatal  period  of  life,  but  they  exhibit  their  characteristic 


si:psis  nkoxatorum  0:5 

pheuuiiiena  just  after  birth.  Tliesu  phenoiiiuua  may,  accordiiiu'  to 
the  route  of  invasion,  take  the  form  of  erythematous,  pemphigoid, 
and  hamorrhagic  cutaneous  manifestations  ;  of  bronchitis,  pneumonia, 
I  ir  pleurisy ;  of  stomatitis,  gastro-enteritis,  or  cholera  infantum :  of 
ophthalmia,  or  of  vulvitis,  urethritis,  and  vaginitis.  In  this  way 
there  occur  in  the  new-born  such  affections  as  septic  diarrhcea,  and 
septic  pneumonia ;  but  the  true  nature  of  these  conditions  has  onh" 
lieen  appreciated  within  recent  years.  It  seems  probable,  also,  that 
in  this  group  of  the  septic  neonatal  infections  must  be  placed  certain 
little  understood  morbid  processes,  to  which  the  names  of  Eitter's 
disease,  Winckel's  disease,  Buhl's  disease,  and  the  h;emophilia  of  the 
new-born  have  been  applied.  In  doing  so,  however,  it  is  necessary 
to  widen  greatly  the  definition  which  used  to  be  accepted  of 
the  germs  which  are  to  be  regarded  as  septic ;  it  must  include, 
not  onlj-  the  streptococcus,  and  the  staphylococcus,  but  also  the 
Bacterium  coli  commune,  a  bacillus  analogous  to  the  Bacillus 
pncumonicc  of  Friedliinder,  the  B.  entcriditis,  etc.  Some  words  of 
description  will  be  given  to  the  diseases  which  are  thus  admitted 
within  the  scope  of  "sepsis  neonatorum,"  but,  in  the  first  place, 
it  will  be  well  to  complete  the  reference  which  is  being  made  to 
neonatal  sepsis  in  its  more  restricted  sense.  All  the  septic  con- 
ditions of  the  new-born  have  this  in  common,  that  they  are  very 
liable  to  prove  fatal.  This  lethal  character  may  be  due  in  part 
to  the  weakness  of  the  phagocytic  or  leucocytic  reaction  at  this 
time  of  life,  and  this  in  its  turn  may  be  a  persistence  of  a  foetal 
peculiarity,  for  in  intrauterine  life  (life  normally  in  sterile  sur- 
roundings) there  can  be  little  need  for  such  a  reaction.  It  may 
Ije  also  associated  with  the  small  degree  of  development  of  the 
lymphatic  glands  and  the  spleen.  There  can  l)e  no  doubt  that 
congenital  debility,  premature  Ijirth,  the  presence  of  malformations 
(such  as  hare-lip),  cleft  palate,  umbilical  hernia),  and  the  coincidence 
of  an  antenatal  disease  (e.g.  syphilis),  will  increase  the  receptivity 
of  the  infant  to  pathogenic,  and  specially  to  pyogenic,  microbes. 
In  this  way  there  is  both  an  increased  septic  mortality  and  mor- 
bidity in  neonatal  life,  and  in  the  production  of  both  there  is  the 
antenatal  factor  evidently  at  work.  The  germs  are  everywhere 
present — in  clothes,  in  baths,  in  CiV(vcuses,  in  maternal  secretions, 
in  the  mouth  of  the  infant,  round  the  umbilicus,  in  the  folds  of 
the  skin ;  the  new-born  is  prone  to  their  attacks,  by  reason  of 
the  peculiarities  of  his  neonatal  physiology,  and  antenatal  pathology, 
and  intranatal  traumatism ;  therefore,  there  is  need  for  an  enlightened 
prophylaxis,  which  shall  not  only  endeavcnir  to  prevent  the  entrance 
of  microbes  along  the  avenues  which  have  been  referred  to,  but 
shall  also  attempt  to  strengthen  all  the  defences  of  the  organism 
against  their  onslaughts  when  they  have  entered. 

H J': MOGLOBIN  UKIA   NEONATORUM. 

A  plurality  of  names  and   an   obscurity   of  pathology  often  go 
together,  the  former  being  bred  of  the  latter ;  so,  at  any  rate,  it  is 


64  ANTEXATAI,    I'ATIlOI.Od^'    AM)    IlVdlENK 

with  regaid  to  tlie  inalaily  nf  tlic  iiew-liniii  called  haMuoglohiiuiria 
iieoiuitoiuui.  Many  iiaiiiL's,  truly.  "  Wiiifkel's  diseaso"  (lui^lit, 
with  enual  appropiiatL'iieHS,  be  "I'dllak's"  disease,  or  "  Uigelow's " 
disease,  or  "  Laroyeniie's,"  or  "  Ciiarrin's  "  disease),  "  liroiized  hamatic 
disease,"  "  renal  tubal  ha'iuatia "  (Parrot),  "  pernicious  icteric  cyan- 
osis "  (Winckel's  own  name  for  it),  and  "  bronzed  lucniaturic  disease 
of  the  new-born."  There  is  one  value,  at  least,  in  the  plurality 
of  names :  a  suggestion  is  contained  therein  of  the  outstanding 
features  of  the  malady.  It  is  rare,  but  wlien  it  occurs  it  is  usually 
in  an  epidemic  form,  and  in  a  Maternity  Hospital.  The  victims 
(nineteen  perished  out  of  twenty-three  attacked  in  one  ei)idemic) 
are  healthy  and  strong  at  birth  ;  two  or  three  days  after  birth  they 
liegin  to  be  ill,  very  ill  in  fact,  dying  in  tliirty-twu  hours,  and  even 
in  a  shorter  time  in  some  cases.  They  have  a  cyanotic-icteric  colour 
of  their  skin,  each  one  appearing  like  a  "  little  mulatto,"  a  peculiar 
lironzed  colour,  almost  violet  on  the  palms  of  the  hands  and  the  soles 
of  the  feet,  the  conjunctiva  sub-icteric.  There  are  fits  of  crying,  alter- 
nating with  somnolent  states.  The  blood  is  black  as  ink,  or  has 
a  chocolate  colour.  The  stools  are  black-green,  and  leave  on  the 
napkins  a  stain  with  a  sanguinolent  areola.  The  urine  is  sanguinolent 
also,  very  markedly  so,  drawing  the  attention  of  the  clinician  at 
once.  There  is  no  fever,  but  a  rapid  pulse.  There  are  head  sym]itonis 
also,  such  as  convulsions  and  squinting.  As  already  hinted,  death 
usually  follows.  The  autopsy  reveals  to  a  verj'  considerable  extent 
the  changes  which  the  syn;ptonuitology  has  led  one  to  expect ; 
there  are  hiemorrhages  in  many  situations,  the  lungs  are  lilack,  the 
cerebro-spinal  fluid  and  that  from  the  pericardial  sac  are  sanguin- 
olent, the  Idadder  contains  sanguinolent  urine,  the  liver  and  spleen 
have  a  lirownish  black  colour,  the  kidneys  are  marone-coloured, 
and  the  pelvis  and  calyces  are  filled  with  a  black-grained  clot. 
There  is  no  disease  of  the  umbilical  vessels :  about  this  point  all 
oliservers  seem  agreed.  The  microscopical  examination  of  the  tissues 
throws  a  faint  tlicker  of  light  into  the  pathological  darkness  of  the 
malady.  In  the  urine  are  to  be  found  epithelial  cells  from  the 
bladder,  epithelial  masses  from  the  calyces,  granular  cylinders  of 
blood  corpuscles,  and  micrococci  in  great  numbers:  there  are 
hu-moglobinuric  infarcts  at  the  level  of  the  papilLe  in  the  kidneys. 
Thus  Winckel.  The  renal  change  is  descrilied  more  minutely  by  Bar : 
there  is  a  blood  ell'usion  into  the  convoluted  tubules  at  the  pajiilla-, 
and  the  effusion  has  acted  uixm  the  renal  epitlielium  liy  compres- 
sion :  the  straight  tubes  show  similar  changes,  especially  marked 
at  the  level  of  the  "  })yramids  of  Ferrein  " ;  in  the  latter  he  found 
elongated  bacteria,  and  in  the  former  micrococci  in  large  numliers, 
arranged  in  chains  or  clusters.  A  micrococcus  also  is  to  be 
observed  in  the  blood,  according  to  Hirst,  and  in  the  liver,  spleen, 
and  lungs ;  rapid  diminution  in  the  red  blood  cells,  5,700,000  one 
<lay,  3,400,000  three  days  later;  ratio  of  white  to  red,  1:  IS'o, 
luemoglobin,  89  per  cent. 

It  was  and  is  an  obscure  disease.     Eesembling  in  some  details 
the  malady  known  as  IJuhl's  disease,  or  acute  fatty  degeneration  of 


OMPHALORRHAGIA  NEONATORUM         Go 

the  new-born,  for  in  both  there  are  ha-morrhages  and  fatty  de- 
generation of  the  internal  organs,  but  differing  in  others.  Obscure 
as  to  its  etiology,  when  it  occurred  in  an  epidemic  form  (Max 
Kunge  {Die  Krankheiten  der  crstcn  Lchcnstaije,  p.  175,  1893)  says: 
"  Die  xEtiologie  dieser  Epidemic  blieb  demnach  dunkel "),  it  was 
also  obscure  when  it  was  met  with  sporadically  ("  auch  blieb  die 
^Etiologie  uuklar,"  Eunge).  One  or  two  things  alone  seem  certain : 
it  is  an  infection;  it  does  not,  primarily  at  any  rate,  aftect  the 
umbiUcus ;  it  is  htemorrliagic ;  anil  it  specially  attacks  the  tubules 
of  tlie  kidney  and  the  blood.  Buhl's  disease  has  been  referred  to. 
In  it  the  fatty  degeneration  of  several  of  the  internal  organs  is  a 
marked  feature :  something  similar  has  been  described  in  the  new- 
born of  other  mammals,  namely,  the  "  La^hme  "  ("  foot-halt ")  of  lambs. 
In  "  Buhl'sche  Krankheit,"  there  are  infarcts,  bleeding  from  the 
bowel  and  stomach,  and  jaundice.  In  some  details  the  disease 
differs  from  ha?moglobinuria  neonatorum:  hjemorrhage  from  the 
umbilicus  is  common,  and  the  subject  has  often  been  in  an  asphyx- 
iated condition  at  birth.  Sepsis  may  be  expected  yet  to  be  clearly 
demonstrated  in  both,  although  it  is  difficult  to  understand  by  what 
avenue  of  entrance  micro-organisms  have  invaded  the  body ;  but 
with  such  cases  as  those  of  Audion  {loc.  cif.)  in  the  nrind,  it  is 
quite  conceivable  that  germs  may  have  passed  in  through  unclosed 
umbilical  vessels,  without  there  being  any  signs  of  disease  in  the 
umbilicus  itself  (persistence  of  antenatal  permeability  ?).  "  Bleibt 
die  -.Etiologie  unklar  ! " 

Omphalokrhagia  Xeonatoru.m. 

Htemorrhage  from  the  umbilicus  is  "  not  a  disease  but  a  symptom 
of  different  morbid  states  "  ("  keine  Krankheit,  sondern  ein  Symptom 
verschiedener  krankhafter  Zustande,"  Bunffc) ;  this,  at  any  rate,  is 
the  modern  view  taken  of  the  idiopathic,  or  secondary,  or  spontaneous 
form  of  omphalorrhagia  in  the  new-born.  With  primary  bleeding 
from  the  stump  of  the  umliilical  cord  from  slipping  of  the  ligature, 
abdominal  constriction  from  the  binder,  etc.,  we  are  not  here  concerned. 
Idiopathic  omphalorrhagia  begins  after  the  fall  of  the  cord ;  often  in 
insidious  fashion,  bleeding  having  begun  and  for  some  time  continued 
before  it  has  been  observed,  perhaps  when  the  infant  is  being  un- 
dressed, and  the  gravity  of  the  case  then  for  the  first  time  recognised. 
The  time  of  commencement,  then,  may  be  fixed  as  between  the 
fifth  and  seventh  days  of  life.  The  sex  more  often  affected  is  the 
male  (males,  65 i|  per  cent. ;  females,  34{  per  cent.) ;  but  the  disease 
is  rare  (once  in  5000  new-liorn  infants,  Winclcd) ;  is  very  fatal  when 
it  does  occur  (mortality,  83  per  cent.,  Grandidkr) ;  and  runs  its 
course  in  a  short  time  as  a  general  rule  (a  few  hours,  at  most  a  few 
days).  The  umbiUcus,  when  inspectetl,  shows  rather  a  steady  and 
general  oozing  or  sweating  of  blood  than  a  distinct  htemorrhage  from 
any  vessel  or  vessels ;  some  clots  may  be  found  in  the  neighbourhood 
of  the  umbilicus,  but  commonly  the  blood  shows  no  tendency  to 
coagulate.  There  may  or  may  not  have  been  premonitory,  at  any 
5 


GG      ANTENATAL  I'ATHOI.OdV  AND  HVOIllM': 

rate  precedent  si^ns,  such  as  vuiiiiting,  souiunleiice,  Jaundice,  colic, 
and  purpuric  si)Ots. 

It  is  inevitalile  that  .such  a  lui-morrhage  sliould  be  regarded  as  of 
tlie  nature  of  the  hereditary  malady  haanophilia,  but  then  omphalor- 
rhagia is  rare  in  families  with  tliis  hereditary  tendency  (1  know 
of  but  one) ;  and  it  does  not  clear  up  matters  to  suggest  that  it 
represents  a  sort  of  "  transitory  hicmorrhagic  diathesis  "  due  to  the 
transition  from  the  fwtal  to  the  neonatal  mode  of  respiration  ("  natiir- 
lich  ist  dies  keine  Erkliirung,  sondern  nur  eine  I'mschreibung  der 
Thatsachen,"  Biitufe).  It  would  seem  that  it  is  sometimes  the  result 
of  congenital  syphilis,  altliougli  it  must  be  freely  confessed  that  all 
evidence  of  the  j)resence  of  parental  syphilis  is  often  al)sent.  It  may, 
as  has  already  been  noted,  be  associated  with  Ihihl's  disease,  an 
association  which  does  not  help  us  much  in  our  search  for  its  causa- 
tion, the  etiology  of  Buhl'sche  Krankheit  itself  l)eing  "unklar"  u]> 
to  this  time.  Sepsis  neonatorum  has  also  been  regarded  as  the 
cause  of  omphalorrhagia  with  some  increasing  degree  of  probability, 
for  various  microbes  have  been  foimd  in  such  cases  (streptococcus, 
staphylococcus  albus,  sta]>bvlococcus  aureus,  special  di])lo-bacillus). 
Finally,  the  antenatal  factor  has  been  invoked,  and  the  condition 
has  been  ascribed  to  malformations  of  the  heart  and  bh)od  vessels. 
Whether  there  is  any  degree  of  truth  in  this  opinion  or  not,  is  not 
easily  decided,  but  there  can  he  no  doubt  that  two  and  even  more 
cases  of  omphalorrhagia  may  occur  in  the  same  family ;  further,  1 
have  notes  of  a  family  history  in  which  the  first  infant  died  of  um- 
bilical hicmorrhage,  and  the  second  was  dead-born  with  grave  mal- 
formations of  the  intestine  and  urinary  bladder'.  Some  evidence, 
therefore,  exists  to  prove  that  the  antenatal  factor  is  not  to  be 
neglected  in  endeavouring  to  distrilnite  the  etiological  blame  aright. 
In  presence  of  such  a  grave  condition  as  omphalorrhagia,  mild  re- 
medial measures  are  comraonlj'  of  little  use,  and  only  occupy  valuable 
time.  The  application  of  various  styptics  and  the  tilling  of  the  imi- 
bilical  fossa  with  plaster  have  been  tried  ;  but  it  is  generally  necessary 
to  resort  to  compression  of  the  umbilicus  or  to  mass  ligatin'e  of  it 
with  the  aid  of  hare-lip  ])ins.  The  umbilical  vessels  may  l)e  sought 
for  and  ligatured  separately,  but  there  is  no  strong  evidence  that  the 
l)leetling  is  specially  from  the  vessels.  The  abdominal  cavity  has 
been  opened  in  one  or  two  cases,  and  the  vessels  tied  on  the  inside, 
but  with  no  good  effect.  Constitutional  treatment  (e.t/.  anti-syphilitic) 
has  not  been  forgotten  ;  Imt  all  means  too  often  fail.  Of  this  disease, 
as  of  some  others  which  aftVct  the  iiew-liorn,  it  may  lie  sadly  said, 
"  prescjue  fatalement  morld." 

IV.   Disturbed   Neonatal   Readjustments. 

It  is  impossible  to  separ^e  ofV  the  maladies  which  are  due  to 
neonatal  infection  from  tliose  ni  which  the  chief  morbid  factor  seems 
to  lie  a  disturbance  of  the  ]i]iysiological  readjustment  which  follows 
liirth.  There  can  be  no  duulit  that  to  some  extent  they  overlap,  lioth 
factors  being  present.     What  I  am  trying  to  do  is  to  group  together 


ICTERUS   NEONATORUM  67 

those  iu  which  the  infection-factor  seems  to  lie  the  more  important, 
and  those  in  which  the  disturbed  readjustment  plays  the  greater 
part.  The  classificatiou,  however,  is  not  insisted  upon,  for  the  object 
of  the  chapter  is  to  show  the  intrusion  of  the  antenatal  factor  into 
all,  or  nearly  all,  the  diseases  of  the  new-born. 


Icterus  Neoxatoru.m. 

Surely  there  is  no  question  in  neonatal  prognosis  more  difficult  to 
settle  than  the  significance  of  jaundice  of  the  new-born  in  any  given 
case.  Certainly  there  is  no  problem  in  neonatal  pathogenesis  farther 
from  solution.  So  common  and  generally  so  benign  as  to  have  gained 
for  itself  the  name  "  physiological,"  jaundice  of  the  new-born  may 
yet  be  due  sometimes  to  one  of  the  rarest  of  malformations,  and  may 
have  a  mortality  that  is  appalling.  Hypotheses  there  are  in  plenty  ; 
but  of  solid,  incontrovertible  facts  few  are  to  be  found,  although 
sought  for  with  care.  One  fact  among  the  few  is  worth  remembering, 
even  if  much  else  be  forgotten :  jaundice  of  the  new-born  is,  like 
omphalorrhagia  neonatorum  (but  even  more),  to  be  regarded  as  a 
sj'mptoni  rather'  than  a  morbid  entity  or  separate  disease.  Another 
fact  is  its  frequency,  and  the  evident  deduction  (but  not  a  fact !) 
would  seem  to  be  that  it  must  therefore  depend  upon  a  fre(;[uent 
condition  or  group  of  conditions ;  it  is  safer,  however,  to  conclude 
that  it  generally  depends  upon  a  frequent  conjunction  of  circum- 
stances, and  ravel  1/  may  be  due  to  quite  exceptional  states.  There  is 
certainly  one  group  of  cases  in  which  the  jaundice  is  slight  and 
transient,  and  so  often  met  with  that  one  is  justified  in  regarding  it 
as  a  symptom  of  a  physiological  state  of  affairs,  the  outward  sign  and 
manifestation  of  the  inner  processes  of  functional  readjustment  and 
adaptation  which  take  place  at  and  soon  after  birth ;  in  this  group, 
the  jaundice  is  by  some  termed  idiopathic  or  spurious  icterus,  or 
icterus  neonatorum  in  the  narrower  sense.  It  is  equally  certahi 
that  there  is  another  group  of  cases  in  which  the  jaundice  is  again  a 
symptom,  but  now  a  symptom  of  a  pathological  condition  —  nay 
rather  of  several  pathological  C(3nditions  of  various  degrees  of  gravity  : 
symptomatic  icterus,  then,  may  be  its  name.  It  is  possilile,  but  there 
is  no  great  strength  of  possibility  about  it,  that  in  such  a  disease  as 
hffimoglobinuria  neonatorum  it  is  the  jaundice  that  is  the  pathological 
condition  that  constitutes  the  disease  itself.  Thus,  to  summarise, 
there  are,  or  may  he,  three  groups : — 

1.  Idiopathic  icterus — the  symptom  of  a  physiological  process 

or    processes  —  a    sign    of   neonatal    readjustment    in 
progress. 

2.  Symptomatic  icterus — the  sympitom  of  a  pathological  pro- 

cess   or    processes — a    sign    of   neonatal    pathology  in 
action. 

3.  Essential  icterus — not  a  symptom  but  the  disease  itself — a 

doulitful   entity  and  class — possibly  will  turn  out  to 
be  a  form  of  symptomatic  icterus,  variety  septic. 


68  ANTRXATAL    PATHOLOGY   AND   HYGIENE 

In  enduavouriii^'  to  liiiil  a  suitalile  pathogenesis  for  idiopathic 
jaundice,  the  patliologist  lias  run  riot,  and  what  witli  his  liepatogcnous 
theories  and  his  h;L'niatogeuous  ones,  there  is  confusion  in  the  minds 
of  not  a  few  writers  and  readers  both.  Here  are  some  of  the  hepato- 
genous theories :  desquamation  of  tlie  epitliehum  in  the  bile-ducts 
leading  to  blocking;  slowing  of  the  portal  circulation  due  to  the 
circulatory  changes  resulting  from  birth  and  the  ligature  of  the 
cord  ;  stasis  in  the  bile-ducts  from  their  compression  by  the  anlema  of 
Glisson's  capsule  due  to  the  phenomena  folhnving  birth  ;  persistence 
of  permeability  of  the  ductus  venosus ;  retention  of  the  meconium  ; 
and  late  ligature  of  tlie  umljilical  cord.  With  respect  to  most,  if  not 
all,  of  these,  Eunge's  remark  {op.  cit.,  p.  228)  holds  true,  "  Keinc 
einzige  dieser  Anschauungen  ist  anatomisch  begriindet,  sie  sind 
sJimmtlich  hypothetscher  Natnr."  They  agree,  let  it  be  noted,  in  one 
thing,  that  they  all  look  for  a  cause  of  the  jaundice  in  one  or  other 
of  the  phenomena  which  follow  Ijirth  as  a  result  of  the  rearrange- 
ment of  functions  made  necessary  by  the  marked  change  in  environ- 
ment then  taking  place ;  they  regard  the  icterus  as  due  in  some  way 
to  disturbance  of  an  absolutely  perfect  performance  of  the  neo- 
natal readjustment.  Tlien,  again,  there  have  lieen  the  lui-matogenous 
theories  which  seem  to  have  Ijeen  widely  held  in  France ;  the  hejmto- 
genous  apparently  Ijeing  popular  in  tJermany.  Destruction  of  red 
blood  corpuscles  after  birth,  setting  free  of  much  pigment  in  tlie 
blood,  changes  in  the  blood  plasma  leading  to  tlie  breaking  down  (if 
blood  corpuscles;  these  and  other  changes  in  the  blood  have  been 
advanced,  but  not  of  late  with  any  great  boldness,  tlie  demonstration 
of  bile  acids  in  the  pericardial  fluid  having  given  apparently  a  deadly 
blow  to  the  hicmatogenous  theories.  This  much,  however,  it  is  worth 
while  remembering:  that  the  luematogenous,  in  common  with  the 
hepatogenous  theories,  look  to  the  readjustment  phenomena  in  the 
new-born,  or  to  a  slight  disturliance  of  them,  as  the  causes  of  the 
blood  or  liver  changes  which  produce  the  jaundice.  Some  investi- 
gators carry  the  inquiry  further  liack,  and  ask  what  cause  or  causes 
contribute  to  the  slight  di.sarrangement  of  the  physiological  readjust- 
ment of  birth  :  some  find  an  explanation  in  errors  of  feeding  during 
the  first  days  of  life;  while  others  conclude  that  delay  in  laliour,  or 
unilue  interference  with  its  mechanism,  has  been  the  disturbing 
condition ;  and  yet  others  are  compelled  to  look  for  the  antenatal 
factor,  and  find  it  in  congenital  weakness  or  prematurity.  Thus, 
idiopathic  icterus  neonatorum  is  due,  according  to  the  opinion  of 
most,  to  a  disturbance  of  the  iihysiological  readjustment  of  hirtli, 
and  this  distiu'bance  is  caused  by  a  neonatal,  an  intranatal,  or  an 
antenatal  factor,  by  one  of  these,  or  perhaps  by  all.  At  any  rate,  and 
to  the  physician  this  is  a  matter  of  moment,  the  condition  usually 
disappears  quickly  and  leaves  no  evil  efiects  behind  it ;  it  is  an 
almost  harmless  disorder,  all)eit  having  "a  well-marked  clinical  indi- 
viduality "  ("  une  individualitc  clini(iue  bien  marquee  "). 

A  different  group  of  circumstances  and  conditions  goes  to  make  up 
the  malady  known  as  aiimptomalic  icterus  neonatorum.  Its  causes  are 
not  unknown,  are  in  fact  well  known,  but  they  are  numerous  and  not 


MEL.ENA   NEONATORUM  GO 

easily  to  be  ditlerentiated  from  each  other  durmg  the  life  of  the  infant 
affected  therewith.  It  is  in  some  instances  due  to  hepatic  lesions, 
neonatal  or  antenatal.  In  this  group  must  be  placed  the  jaundice 
which  follows  umbilical  infection  with  sepsis ;  that  which  is  caiised 
by  syphilitic  hepatitis  of  the  congenital  type ;  and  that  produced  by 
interstitial  hepatitis,  the  syphilitic  nature  of  which  cannot  be  proved. 
It  is  in  other  instances  due  to  obstacles  to  the  How  of  the  bile, 
obstacles  which  have  arisen  in  the  neonatal  period  or  in  the  ante- 
natal. Thus  it  may  originate  in  a  catarrhal  blocking  of  the  common 
bile-duct,  at  the  point  where  it  passes  through  the  wall  of  the  duo- 
denum ;  or  it  may  arise  in  that  interesting  malformation,  or  result  of 
antenatal  disease,  known  as  congenital  obliteration  of  the  bile-ducts, 
and  it  may  then  be  justly  termed  "  malignant  icterus,"  for  it  is  always 
fatal  sooner  or  later  ;  or  it  may  be  caused  by  the  impaction  of  a  small 
gall-stone  in  the  ductus  communis  choledochus  or  in  the  cystic  duct, 
it  being  necessary  in  such  a  case  to  believe  that  the  calculus  was 
formed  in  intrauterine  life  (antenatal) ;  or  it  may,  finally,  be  the 
result  of  an  over-production  of  bile  leading  to  obstruction  in  the 
ducts.  In  this  multitude  of  causes  it  is  to  be  noted  again  that  the 
antenatal  factor  occupies  a  not  unimportant  place,  and  when  it  is 
present  in  any  given  case  it  largely  increases  the  difficulty  of  treating 
the  jaundice,  and  makes  the  prognosis  correspondingly  worse.  The 
hope  of  the  physician,  in  one  sense,  lies  in  the  confirmation  of  the 
diagnosis  of  catarrhal  lilocking  or  of  syphilitic  hepatitis,  for  castor- 
oil  in  the  one  case  and  mercury  in  the  other  may,  and  does,  work 
wonders ;  the  diagnosis  of  congenital  obliteration  of  bile-ducts  or 
impaction  of  an  antenatally  formed  gall-stone,  a  diagnosis  made 
largely  as  a  matter  of  exclusion,  raises  little  therapeutic  expectation. 

MEL.EXA   NeONATOKU.M. 

In  cases  of  gastro-intestinal  hiemorrhage  in  the  new-born,  the 
lileeding  is  generally  from  the  bowel  (mekena),  and  rarely  from  the 
mouth  (h;ematemesis) ;  it  has  therefore  become  customary  to  apply 
the  name  "  mekena  neonatorum  "  to  the  disease.  That  it  is  to  be 
regarded  as  a  disease  is,  however,  more  than  doubtful ;  it  is,  in  fact, 
no  more  a  disease  than  icterus  ;  it  is,  like  icterus,  a  symptom  of  several 
different  morbid  states.  Generally  a  symptom  among  other  symptoms, 
it  may  in  some  rare  instances  stand  alone  as  the  only  symptom  ;  then, 
and  then  only,  is  it  justifiable  to  call  it  a  disease — a  morbid  entity. 
Unlike  jaundice  of  the  new-born,  it  is  a  very  rare  condition,  occurring 
but  once  in  500  or  700  new-born  infants ;  there  is  no  great  resem- 
blance either  in  the  matter  of  prognosis,  for  melfena  neonatorum  is 
very  often  fatal,  mortality  being  from  35  per  cent,  to  50  per  cent., 
even  from  50  per  cent,  to  60  per  cent,  according  to  Eunge.  In  one 
thing  the  two  conditions  fully  and  entirely  agree  :  in  the  multitude 
of  theories  which  pathologists  and  physicians  have  lirought  forward 
to  explain  their  patlmgenesis.  Many  of  the  theories  are  not  founded 
upon  even  the  slightest  stratum  of  anatomical  fact,  there  being  no  trace 
of  solid  bed-rock  in  the  .shifting  sand.     Some  of  the  theories  condenm 


70  AXTKNATAL    1*ATH()L()(;Y   AND    HV(;iENE 

themselves  to  llic  tliiiikin<^  iiiiiid  at  once ;  those,  namely,  in  wliicli  a 
very  common  occurrence,  such  as  early  or  late  ligature  of  the  umbilical 
cord,  is  blamed  for  the  production  of  mekena  neonatorum,  ailmittedly 
a  very  rare  condition.  Surely  it  must  be  conceded  at  (jnce  that  a  rare 
morbid  state  demands  for  its  causation  a  condition  which  is  also  rare, 
or  at  least  a  rare  conjunction  of  common  conditiims.  As  it  is,  the 
pathogenetic  theories  of  mehena  neonatorum  are  in  a  state  of  hopeless, 
bewildering  confusion.  There  is,  perhaps,  little  service  to  be  got  out 
of  an  attemi)t  to  arrange  them  ;  but  there  is  for  our  present  ]iurpose 
some  interest  in  so  far  as  it  gives  a  demonstration  of  the  way  in  which 
the  four  great  factors,  traumatism,  infection,  disturbed  neonatal  re- 
adjustment, and  the  antenatal  factor,  are  all  in  turn  invoked  and  com- 
bined in  various  ways,  and  shutHed  like  a  pack  of  cards  in  the  hope 
that  here  or  there,  in  this  circumstance  or  that,  a  feasible  explanation 
may  be  forthcoming.  A  little  simplification  is  possible  :  there  are 
some  cases,  at  any  rate,  in  which  the  melsna  is  evidently  tlie  result 
of  blood  swallowed,  e.g.  from  a  hare-lip  or  cleft  palate,  or  from  the 
nose  or  lungs  ;  more,  the  blood  may  not  even  belong  to  the  infant,  but 
come  from  the  maternal  nipple  :  certainly  there  is  justiticatiou  in 
separating  ott'  these  cases  and  giving  them  a  special  name,  with  a 
warning  that  they  are  not  to  intrude  any  more  into  the  etiology  of 
mehena  neonatorum.  Separated  otl',  therefore,  they  have  been,  and 
have  been  called  "  mehena  spuria."  With  the  remainder,  what  is  to 
be  done  ?  Let  us  see  how  they  arrange  themselves  under  the  four 
great  etiologic  factors.  Perchance  this  uietlmd  cif  regarding  tliem 
may  be  of  some  small  service. 

First,  then,  there  is  traumatism,  intranatal  or  neonatal.  Com- 
pression of  the  trunk  of  the  infant  in  birth,  violent  procedures  adopted 
to  restore  the  half  asphyxiated  child,  swinging  movements,  for  instance, 
after  birth,  have  been  suggested.  Two  difficulties  immediately  suggest 
themselves  :  such  traumatic  occurrences  are  common,  while  melaena 
is  rare  ;  cases  of  mehena  rarely  follow  sucli  traumatic  occurrences. 
Traumatic  factor,  however,  is  not  to  be  driven  out  of  the  field  so 
easily  ;  according  to  F.  von  Preuscheu  {Ccntrlhl.  /'.  (r'l/niil:,  xviii.  201, 
1894),  the  traumatic  part  of  the  process  is  to  be  looked  for  in  the 
cranium,  where  h;emorrhages  have  destroyed  some  portion  of  the 
central  nervous  system — a  theory  founded  upon  the  exjieriments  of 
Scliift"  and  others  upon  the  production  of  gastric  luemorrhage  in  dogs, 
and  supported  to  some  extent  by  Schiitze's  case,  in  which  there  was 
a  small  hivmorrhage  under  the  tentorium  cerebelli  {ibid.,  p.  207). 
Intracranial  hajmorrhages,  it  must  be  borne  in  mind,  are  not  so  rare  as 
sujiposeil,  and  are  certainly  many  times  present  when  melfeua  is 
absent. 

Second,  there  is  infection,  intranatal  or  neonatal.  The  theories 
founded  upon  some  sort  of  infection  are  wonderfully  popular  at  the 
present  time.  Tiie  special  form  which  the  infection  takes  may  be 
septic,  and  it  is  not  doubted  that  gastro-intestinal  liiFmorrhages  occur 
in  sejisis  neonatorum :  it  may  also  take  the  form  of  Buhl's  disea.se, 
and  be  caused  by  the  microlie  ]ieculiar  to  it;  or,  it  niaj'  be  due  to 
a  bacillus  jieculiar  altogether,  as  F.  Giirtner  (Arch.  f.  Gi/mik.  xlv. 


MEL.EXA    NEOXATOHLM  71 

272,  1893)  aud  those  who  have  followed  his  lead  have  maintained. 
It  is  unfortunate  for  the  acceptance  of  this  theory,  that  so  many 
microhes  have  been  discovered :  streptococcus  alone  or  with  the 
diplococcus  of  pneumonia,  bacillus  pyocyaneus  alone  or  with  the 
staphylococcus,  bacillus  lactis  aerogenes,  a  bacilhis  like  Friedliinder's, 
a  bacillus  like  Kolb's  found  in  purpura  luemorrhagica,  Gartner's  bacillus 
above  referred  to,  and  a  micro-organism  suggesting,  but  not  to  be 
identified,  with  the  diplococcus  of  pneumonia.  A  bacteriological 
"embarras  des  richesses"  is  thus  created,  which,  as  has  been  pointed 
out  by  Kilham  and  Mercelis  {Arch.  Pcdiat.,  xvi.  161,  1899),  adds  to 
the  confusion,  aud  does  not  increase  the  jirobability  of  the  existence 
of  any  specific  microbe. 

Third,  there  is  disturbed  neonatal  readjust]nent.  A  large  number 
of  pathogenetic  theories  is  associated  with  this  factor.  Further,  most 
of  the  theories  look  to  a  disturbance  in  one  part  of  the  readjustment 
phenomenon,  in  that,  namely,  which  has  to  do  with  the  circulation. 
Of  course  it  is  at  once  apparent  that  any  irregularity  in  the  com- 
plicated series  of  changes  (physiological  and  anatomical)  which  marks 
the  transition  from  the  foetal  to  the  neonatal  circulation,  will  be  likely 
to  produce  congestive  conditions  in  one  part  of  the  vascular  system 
and  anaemic  conditions  in  another.  It  is  in  this  way  that  early  or 
late  ligature  of  the  cord,  thrombosis  in  the  iimliilical  vein  from 
delayeil  establishment  of  the  pulmonary  circidation,  and  other 
frequently  occurring  irregularities,  have  been  invoked  as  pathogenetic 
factors.  The  fact  that  it  is  common  to  find  at  the  autopsies  of  infants 
who  have  died  from  melajna  erosions,  defects,  and  even  ulcers  in  the 
mucous  memljrane  of  the  duodenum,  stomach,  and  oesophagus,  is  not 
regarded  as  weakening  this  theory.  For  it  is  ingenioiisly  argued :  there 
has  been  slackening  of  the  circulation  in  the  umbilical  vein  with 
formation  of  a  thrombus,  and  later  from  that  thrombus  pieces  have 
separated  and  have  been  carried  as  emboli  into  the  small  arteries  in 
the  gastric  or  intestinal  walls,  where  the}'  have  produced  local  death 
of  the  tissues,  and  partial  digestion  of  the  mucous  membrane  has  taken 
place,  with  exposure  of  the  vessels  and  hemorrhage.  These  little  de- 
fects or  ulcers  are,  it  is  said,  found  in  45  per  cent,  of  the  cases.  It  is  an 
ingenious  theory,  but  still  a  theory  only.  Another  purely  theoretic  view 
is  that  the  haemorrhage  is  due  to  the  closure  of  the  ductus  arteriosus 
at  a  relatively  slower  rate  than  the  foramen  ovale,  causing  increased 
pressure  in  the  abdominal  arteries.  Other  theories  are  retention  of 
the  meconium  and  the  exposure  of  the  infant  to  cold.  That  in  many 
of  the  cases  of  melajna  neonatorum  the  bleeding  is  concerned  in  some 
way  with  disarrangement  of  the  readjustment  processes,  and  more 
especially  with  the  vascular  part  of  the  adaptation,  must,  I  think,  be 
admitted  as  exceedingly  probable ;  but  here  again  the  pathologist  is 
lirought  face  to  face  with  the  ol  ijection  that  such  vascular  disturbances 
must  be  very  common,  while  melwna  is  very  rare.  Consequently 
many  observers  have  welcomed  the  idea  of  an  antenatal  cause  or  pre- 
disposition. 

Fourth,  the  idea  that  an  antenatal  factor  must  be  looked  for  in 
melffiua  neonatorum  is  not  new.     Further,  it  has  taken  many  forms ; 


7l'  ANTI'.NAIAI.    I' Al  IIOI.OCY    AM)    HYCilKNE 

and  it  has  cither  stood  liy  itself  or  lias  Ijeeii  regarded  as  accessory  to 
other  factors.  In  one  of  its  simplest  forms  it  is  the  recognition  of 
meli«na  as  a  manifestation  of  h;emoi)hilia ;  and  the  obvious  objection 
that  there  is  no  hereditary  history  of  that  disease,  nor  indeed  any 
otlier  sign  of  it,  then  or  later,  is  explained  away  by  regarding  it  as  a 
teinporar}-  lucniorrhagic  diathesis  in  the  new-horn.  Nevertheless,  in 
some  eases,  it  is  prolialdy  a  correct  explanation  ;  for  in  women  ha-nio- 
])hiHa  may  show  itself  only  as  post-i>artum  iKcmorrhage,  and  ])(issibly 
the  new-born  may  under  certain  circumstances  show  it  only  as  melana. 
Another  view  is  that  the  disease  is  congenital  purpura,  and  has  been 
transmitted  from  the  mother ;  Diehl  {Ztxchr.  f.  Gvhurtsh.  v.  Gyiuik., 
xli.  218,  1899)  has  reported  a  case  in  which  this  transmission  seems 
to  have  taken  place,  but  it  is  exceedingly  rare.  Malformation  of  the 
heart  or  great  vessels  is  another  form  the  antenatal  factor  lias  taken, 
and  fongenital  syphilis  of  the  ha^morrhagic  type  is  another. 

Sucli,  then,  are  the  etiological  theories  of  mela-na  neonatorum. 
Their  enumeration  has  at  least  demonstrated  the  presence  of  the 
antenatal  factor  ;  it  has  possilily  done  nothing  else  of  any  value.  Let 
it  be  added  to  the  foregoing,  that  in  some  cases  of  mehena  no  patho- 
logical changes  at  all  have  been  found,  and  the  reader  will  be  impelled 
to  say  with  Demelin  (Comby's  Traitd  dcs  mal  dc  I'enf.,  ii.  143,  1S97), 
"  la  pathogenie  est  loin  d'etre  simple."  And  as  to  treatment  ?  That, 
likewise,  is  "  far  from  simple,"  save  in  the  cases  where  it  is  just 
nothing  at  all ;  in  sucli  it  has  a  simplicity  truly,  but  not  one  of  the 
right  kind.  Doubtless  prevention  is  l>etter  in  niekena  neonatorum 
than  any  attempt  to  cure ;  but  a  wise  prophjdaxis  depends  upon  a 
knowledge  of  the  pathogenesis  and  etiology,  and  that  is  still  wanting. 
Theoretically,  it  may  l)e  said  that  we  ought  to  endeavour  to  favour 
the  readjustment  of  functions  at  birth  ;  but,  practically,  this  is  not 
easy  to  do  unless  we  know  wherein  and  how  the  readjustment  is  fail- 
ing. In  tlie  presence  of  a  well-marked  case  of  mcla-na,  it  will 
generally  be  wise  to  keep  the  body  of  the  infant  warm  (for  the 
application  of  cold,  e.;/.  ice,  to  the  abdomen  has  met  with  no  con- 
spicuous success),  and  to  give  some  styptic  internally.  Possibly  it 
may  be  found  that  the  injection  of  a  solution  of  gelatin  (5  per  cent, 
to  10  per  cent.)  into  the  bowel  will  give  good  results. 

Kekatolysis  Xeoxatokum. 

Under  this  name,  or  under  its  synonyms  (Dermatitis  exfoliativa 
neonatorum,  Eitter's  disease,  Dermatitis  erysipelatosa)  is  known 
an  affection  of  the  new-born,  whose  most  prominent  symptom  is 
an  exaggerated  cuticular  desquamation.  I  say  "  exaggerated,"  for 
there  is  a  physiological  furfuraceous  or  finely  lamellar  exfoliation 
of  the  epidermis  wliicli  occurs  in  all  new-born  infants.  It  is  one 
of  tlie  outward  manifestations  of  the  readjustment  changes  which 
follow  birth  :  but  there  is  some  degree  of  mystery  as  to  its  causation, 
possibly  it  may  be  produced  simi)ly  by  tlie  drying  of  the  epidermis 
in  the  absence  of  the  liquor  aninii,  possibly  there  is  a  deeper  seated 
and  more  recondite  cause  than  that.     At  any  rate,  a  clearing  up 


KERATOLYSIS   XEOXATORUM 


of  our  knowledge  of  tlie  physiological  desquamation  of  the  new-ljoru 
could  not  but  prove  of  value  in  elucidating  the  pathogenesis  of  Eitter's 
disease.  In  Figs.  6  and  7  are  high  and  low  power  niicro-plintcigraphs 
I  if  the  appearances  of  tlie 
skin  in  a  new-born  infant, 
with  perhaps  an  excessive 
degree  of  desquamation, 
certainly  with  a  well 
marked  degree  of  it.  The 
looseness  of  attachment  of 
the  layers  of  the  stratum 
corneum  is  in  these  clearl}- 
displayed,  and  there  can 
lie  no  doubt  that  in  the 
new-born  the  normal  in 
this  respect  very  easily 
may  pass  over  into  the 
pathological.  In  Eitter's 
disease,  however,  there  are 
other  signs  than  epidermic 
des([uaniation.  There  are, 
according  to  Eitter  him- 
self (1)  a  prodromal  stage, 
in  which  there  is  a  dry  scaly  condition  of  the  epidermis ;  (2)  a  stage 
of  erythema  and  exudation;  (3)  one  of  exfoliation  and  drying,  the 
desquamation  following  progressively  the  march  of  the  redness ;  (4) 
one  of  reintegration  of  the  epidermis,  accompanied  liy  a  fading  of  the 
erythema ;  and  (5)  a  stage 
of  sequeke,  such  as  boils, 
abscesses,  and  eczema. 
Often  the  whole  process, 
prior  to  the  sequeke,  is 
completed  without  severe 
constitutional  symptoms ; 
but  there  may  in  some 
cases  be  diarrhcea  and 
pneumonia.  I  have  met 
with  a  case  of  keratolysis 
neonatorum  in  which  the 
symptoms  were  torpidity, 
rejection  of  food  from  the 
mouth,  unless  it  were  put 
far  back  on  the  tongue, 
highly  coloured  stools,  and 
swelling  of  the  parotid 
glands ;  at  ten  days  after 
birth  the  cord  had  not 
separated ;  the  child  died  when  a  fortnight  old ;  it  had  been  born 
after  a  dry  labour,  and  the  dcsc^uamation  was  going  on  at  birth. 

A  most  puzzling  malady  this  has  proved  to  the  physicians  who 


74  ANTKNATAI.    I'Al'HOI.OGV    AND    HYCilKNK 

have  met  with  it,  a  charat'lcr  which  it  lias  in  I'liiiiinnii  with  maiij'  other 
neonatal  diseases.  Possibly  it  is  to  be  lenaidwl.  like  suvciai  other 
morbid  states  of  tlie  new-born,  as  a  syni])tom  rather  than  a  disease 
by  itself.  It  may,  for  instance,  be  a  symptom  of  sepsis,  in  which  case 
we  invoke  the  factor  of  neonatal  infection ;  it  may  be  the  resnlt 
of  an  exaggeration  of  the  phy.siologicaI  exfoliation  of  the  cuticle, 
in  which  case  the  readjustment  factor  is  brought  into  the  etiology; 
or  it  may  be  the  consequence  or  accompaidment  of  an  intrauterine 
disease,  such  as  fa>tal  measles,  scarlet  fever,  or  erysipelas,  in  which 
case  it  is  the  antenatal  factor  that  is  being  advanced.  We  must, 
it  is  to  be  feared,  leave  it  where  Caspary  {Vicrtdjahrschr.  f.  Derm, 
u.  Si/ph.,  xi.  122,  1884)  left  it  sixteen  years  ago — "an  epidermolysis 
of  unknown  nature,  with  secondary  hyjiencmia  of  the  cutis." 

I'EMi'Hii ;i:s  Neonatorum. 

Another  disease  (or  symptom  of  disease)  of  the  new-born,  which 
is  probably  connected  with  a  disturbance  of  the  readjustment  pro- 
cess, in  so  far  as  it  affects  the  skin,  is  i)emphigus  neonatorum.  A 
great  deal  has  been  done  within  recent  years  to  elucidate  the  bullous 
conditions  of  the  skin  of  the  new-born,  and  there  has  been  an  attempt 
to  get  rid  of  the  term  "  pemphigus,"  and  to  put  in  its  place  such 
names  as  "congenital  bullous  dermatitis,"  "epidermolysis  liullosa," 
"congenital  dermatitis  herpetiformis."  Reference  will  be  made  to 
it  in  another  part  of  this  work ;  in  the  meantime,  it  may  be  said 
that  for  its  explanation  it  has  been  found  necessary  not  only  to 
invoke  the  readjustment  and  infection  factors,  but  also  the  antenatal, 
in  so  far  as  most  authorities  have  been  led  to  ascribe  the  malady 
to  a  congenital  and  often  hereditary  vulnerability  of  the  skin,  even 
when  there  have  been  no  lesions  present  at  birth. 

SCLERE.MA   NeONATOKUM. 

Sclerema  of  the  new-born  is  a  grave  disease,  characterised  by 
induration  of  the  subcutaneous  cellular  tissue,  and  a  lowering  of  the 
body  temperature ;  and  more  widely  diffei-ent  and  even  conflicting 
theories  have  been  advanced  to  explain  its  origin  than  have  been 
brought  forward  in  connection  with  any  other  neonatal  morbid 
condition.  Truly  a  ])lurality  of  theories  is  present,  with  not  a 
little  of  the  "gnesser's  darkening  of  knowledge";  a  bad  omen  for 
the  emergence  of  truth.  It  can,  at  any  rate,  generally  be  separated 
from  "  oedema  neonatorum,"  which  is  almost  certainly  a  symjitom 
rather  than  a  disease  per  sc.  The  readjustment  factor  has  been 
sought  for  and  found  in  the  conditii)n  of  the  subcutaneous  fat 
at  and  about  the  time  of  birth ;  it  is  more  easily  solidified  by 
a  fall  in  temperature,  and  the  new-liorn  infant  which  is  not  kept 
warm  becomes  scleremic.  But  it  may  very  fairly  be  asked,  why, 
then,  is  sclerema  neonatorum  comparatively  so  rare,  for  certainly 
many  infants  ai-e  allowed  to  become  chilled  ?  Further,  in  a  case 
which  I  .saw  some  years  ago  (35),  the  microscopical   appearances 


SCLEREMA  NEONATORUM  75 

of 'the_  subcutaneous  tissue  suggested  something  very  different  from 
simple"  solidification  of  the  adipose  layer ;  they  showed  an  invasion 
of  the  layer  by  bands  of  connective  tissue,  and  an  atrophy  of  the 
fat  cells  (Fig.  8).  Another  origin  for  the  disease  was  found  in 
the  cardio-vascular  readjustments  at  birth,  or  in  the  disturbance 
of  them.  Some  writers  identified  sclerema  with  morbus  coeruleus ; 
others  grouped  it  with  the  infections,  and  saw  in  it  an  unusual 
form  of  erysipelas  neonatorum.  The  antenatal  factor  (a  convenient 
one  in  the.se  cases,  about  whicli  our  ignorance  is  the  densest)  has 
of  course  been  long  in  the  field,  and  has  ranged  from  icctal  syphilis 
and  myocarditis,  to  anomalies  of  the  lymphatics  and  antenatal  lesions 
of  the  thermic  nervous  centres.  What  I  wrote  in  1895  (4,  p.  53) 
I  may  with  safety  place  again  here :  "  It  would  seem  as  if  nothing 


lessjthan  the  labours  of  an  international  connnittee  of  investigation 
might  succeed  in  clearing  up  the  confusion,  and  in  undoing  the 
results  of  the  erroneous  generalisations  of  the  past  century."  Spes 
incerta!  At  any  rate,  the  malady  affords  another  instance  of  the 
intrusion  of  the  antenatal  factor  into  the  pathology  of  the  new-born, 
and  to  illustrate  this  intrusion  has  been  the  chief  object  of  this  and 
of  the  preceding  chapter. 

There  are  yet  other  morbid  states  of  the  new-born,  such  as 
asphyxia  neonatorum,  and  neonatal  heart  disease,  in  which  a  dis- 
turbance, or  rather  a  complete  arrestment  of  the  physiological 
readjustment  at  birth,  is  very  evidently  present.  In  them,  also, 
it  is  not  difficult  to  recognise  the  antenatal  factor  in  the  background 
of  the  etiologv. 


70  ANTENATAL    I'ATI  lOI.OdV    AND    HYGIENE 

Summary. 

From  lliL'  fads  wliicli  have  been  euuiiierated,  it  is  clearly  evident 
that  if  the  characters  of  the  diseases  of  the  new-born  infant  are  to  be 
understood,  it  is  essential  that  account  lie  taken  not  only  of  the  circum- 
stances that  the  infant's  organism  has  just  passed  through  a  period  of 
traumatism,  and  is  passing  through  one  of  readjustment  to  meet 
new  requirements  in  a  new  environment  in  which  microbes  are 
plentiful,  but  also  that  during  the  nine  months  of  intrauterine 
life  which  precede  birth,  it  may  have  been  the  sphere  of  morbid 
processes  which  have  left  their  impress  upon  it.  It  may  come 
into  its  extrauterine  surroundings  already  diseased,  or  malformed, 
or  predisposed  to  some  pathological  development.  Like  pregnancy, 
neonatal  life  is  an  epoch  which  has  a  physiology  in  many  respects 
peculiar  to  itself,  and  which  borders  very  closely  on  the  patho- 
logical, tending  very  easily  to  pass  over  into  it.  Further,  just  as 
eveiy  woman  l)rings  with  her  into  her  pregnancy  the  results  of 
her  past  iiathological  history,  so  the  new-born  infant  brings  with 
him,  out  of  his  antenatal  life  into  his  neonatal  existence,  the  effects 
of  any  morbid  processes  which  may  have  attacked  him  in  utero. 
In  this  way  the  j)athology  of  pregnancy  and  the  maladies  of  the 
new'-born  infant  are  both  invested  with  jjeculiarities ;  in  the  former 
there  is,  among  other  things,  the  pathology  of  pre-reproductive 
maternal  life ;  and  in  the  latter  there  is,  among  other  factors,  the 
pathology  of  antenatal  ftetal  and  endjryonic  life. 


BOOK    II 

THE   PATHOLOGY   AND   HYGIENE   OF   THE   F(ETUS 
CHAPTER   VII 

Diseases  of  the  Foetus ;  General  Characters  of  Fcetal  Life  ;  Contrast  between 
Embryonic  and  Fcetal  Life  ;  The  Neofcctal  Period  ;  Anatomy  and  Physio- 
logy of  the  Xeofretal  Period  ;  External,  Internal,  and  Environmental 
Changes  in  the  Xeoftetal  Epoch  ;  F(etal  Growth  and  Development  at  the 
successive  Months  of  Intrauterine  Life  ;  Summary. 

Ix  this  chapter  a  beginuing  is  made.  In  previous  chapters  the 
general  relations  of  Antenatal  Pathology  to  Postnatal  and  Neonatal 
Pathology  were  considered ;  in  this  chapter,  and  in  those  that  follow 
till  the  end  of  the  volume  is  reached,  it  is  Antenatal  Pathology  itself 
in  all  its  wonderful  variety  of  phenomena  that  is  the  subject  of  study. 
A  beguuiing,  then,  is  made  with  Antenatal  Pathology  ;  but  it  is  not 
purposed  to  begin  at  the  beginning  of  Antenatal  Pathology.  To  do 
so  would  be  to  begin  with  the  most  obscure  and  most  difficult  part 
of  it,  namely,  Germinal  Pathology.  It  is  Ijetter,  in  every  way,  to 
commence  with  Fcetal  Pathology.  When  that  has  been  mastered,  it 
will  be  easier  to  deal  with  Embryonic  Pathology  ;  and,  thereafter,  even 
Germinal  Pathology  will  have  its  darkness  to  some  degree  illumined. 
For  the  fcetal  period  of  antenatal  life  is  that  lying  nearest  to  post- 
natal, and  in  this  case  proximity  means  some  degree  of  similarity. 
Fcetal  Pathology  has,  indeed,  much  in  common  with  Neonatal  and 
Postnatal  Pathology,  has  certainly  much  more  in  common  with  them 
than  Embryonic  Pathology,  which  at  first  sight  seems  to  have  nothing 
at  all  in  common,  to  be  entirely  foreign  to  them.  This,  however,  is 
not  quite  true,  and  the  study  of  Fcetal  Pathology  will  show  it.  It  is, 
then,  convenient  and  reasonable  to  begin  Antenatal  Pathology  with 
the  part  which  in  its  manifestations  most  closely  resembles  the 
morbid  processes  of  later  life.  What  we  know  of  Postnatal  Pathology 
is  thus  made  to  throw  light  upon  the  darkness  of  Fa^tal  Pathology, 
and  by  and  by  what  we  shall  find  out  about  Fu^tal  Pathology  will 
carry  the  light  onward,  not  intensifying  it  in  transmission,  into 
the  thick  darkness  of  Embryonic  and  Germinal  Pathology.  Natura 
in  o2}crationibi(s  suis  non  facit  saltum ;  let  us  try  to  imitate  nature 
by  endeavouring  pi-ogressively  to  find  out  the  secrets  of  these  opera- 
tions with  which  she  astonishes  and  humbles  us. 


78  ANll-AATAl.    1'ATH()L()(;Y    AND    HYGIENE 


General  Characters  of  Foetal  Life. 

As  it  is  ueci'ssiiry  Id  be  afiiuaiiiluil  wilh  ihe  ]iliysiology  and 
anatomy  of  the  new-liorn  infant  in  order  to  understand  the  peculiar- 
ities of  neonatal  diseases,  so  a  knowledge  of  the  physiology  and 
anatomy  of  the  fcetus  throws  much  light  upon  fo'tal  patholog}'. 
There  are  many,  many  problems  connected  with  these  subjects  still 
awaiting  solution;  but  enough  is  known  of  intrauterine  life  and 
health  to  help  materially  in  elucidating  the  causes  of  intrauterine 
death  and  disease.  Let  us  try  to  form  a  general  conception  of  the 
ciiaracters  of  fcetal  life. 

The  chief  feature  of  intrauterine  life  is  its  parasitism  or  semi- 
parasitism.  The  fietus  spends  the  whole  of  its  existence,  which 
lasts,  roughly  speaking,  aliout  seven  and  a  half  calendar  or  eight 
lunar  months,  in  the  interior  of  the  uterus.  It  is  immediately 
surrounded  by  the  liquor  amnii,  which,  serving  as  a  natural  water- 
cushion,  protects  it  from  sudden  shocks  and  jars  ;  the  uterine  walls,  by 
their  growth  and  distensibility,  allow  increase  in  size  and  freedom  of 
movement  to  the  ftetus,  while  they  shield  it  from  harm,  and  maintain 
by  their  vascularity  that  constant  temperature  .so  needful  for  healthy 
development ;  and,  external  to  the  uterus,  are  the  ]iartly  osseous, 
partly  muscular  pelvic  and  abdominal  walls,  which  serve  still  f\uther 
to  secure  the  safety  of  the  tender  organism.  In  its  protected  position 
the  foetus  makes  little  call  upon  several  of  its  organs ;  its  lungs  are 
absolutely  quiescent;  its  stomach,  intestine,  kidneys,  lymphatic 
glands,  and  skin  are  largely  in  a  resting  state.  The  heart  and  liver, 
however,  are  active ;  and  the  thymus,  thyroid,  suprarenal  glands  and 
sympathetic  system  play  a  very  considerable  part  in  the  physiology 
of  intrauterine  life.  The  brain  and  spinal  cord,  more  especially  the 
cord,  are  (piite  capable  of  replying  to  all  the  demands  which  are 
made  upon  them,  their  activity  lieing  chiefly  of  the  reflex  type  during 
this  period  of  existence. 

The  most  important  and  the  most  active  of  the  fcetal  organs  lias 
not  yet  been  referred  to ;  it  is  doubtless  extra-corporeal,  and  the 
foetus  is  only  part  jiossessor  in  it ;  nevertheless  it  is  the  dominating 
influence  in  foetal  life,  and  is  absolutely  essential  to  the  unborn  infant. 
Without  the  jilacenta,  intrauterine  existence  in  the  fcetal  periotl  is 
impossible  ;  with  it,  in  a  healthy  condition,  almost  all  the  other  organs 
can  be  dispensed  with.  Ftx'tal  vitality,  although  not  structural 
integrity,  may  be  maintained  by  the  aid  of  the  placenta  alone.  The 
brain  and  the  spinal  cord  may  be  absent;  the  intestines  may  l)e 
occluded  at  several  places  or  reduced  to  a  few  coils ;  the  mouth 
and  anus  and  nares  and  pharynx  may  be  imperforate :  the  lungs, 
kidneys,  liver,  and  spleen  may  be  wanting;  and  the  heart  may  be 
little  more  than  a  dilatation  upon  the  chief  blood  vessels ;  yet  so  long 
as  the  placenta  is  available,  fretal  life  can  go  on.  Nay  more,  tlu^ 
headless,  ami  limbless,  and  almost  trunkless  fa;tus  known  as  an 
allantoido-angiopagous  twin  of  the  anidean  type,  does  not  require 
even  a  heait  in  order  to  continue  in  life,  so  long  as  he  can  maintain  a 


EMBRYONIC   AND    Fayi'AL   LIFK  70 

connection  with  a  corner  of  his  twin-l)rother's  placenta.  The  placenta, 
then,  is  physiologically  necessary  to  the  fa>tus,  and  the  fa'tal  economy 
is  complete  only  when  it  inclndes  the  umbilical  cord,  the  placenta, 
and  the  membranes.  The  important  facts  in  foetal  physiology,  there- 
fore, are — (1)  The  preponderating  influence  of  the  placenta,  which  is 
really  lungs,  kidneys,  stomach,  and  perhaps  even  liver  to  the  unborn 
infant;  and  (2)  the  characters  of  the  intrauterine  environment, 
which  may  be  described,  in  a  phrase,  as  life  in  a  fluid  medium  of  high 
and  practicall}-  constant  temperature,  in  the  dark,  and  with  almost 
complete  protection  from  external  violence.  Fcetal  life,  in  short,  is 
semi-parasitism  upon  the  mother  through  the  placenta. 


Contrast  between  Embryonic  and  Foetal  Life. 

The  chief  result  of  the  physiological  activity  of  the  fcetus  is 
growth,  growth  of  a  remarkable  kind  and  taking  place  at  a  remark- 
able rate,  but  growth  alone ;  there  are  no  striking  alterations  in  the 
relation  of  the  various  parts  of  the  organism  to  one  another,  no 
fusions,  no  separations  of  parts ;  and  in  the  head,  and  the  limbs,  and 
the  liver,  and  the  intestine  of  a  full  time  fcetus  we  can  recognise  with 
no  ditticulty  these  structures  as  they  occurred  in  the  foetus  of  three 
mouths,  only  they  were  then  much  smaller  in  size.  In  this  respect, 
the  result  of  foetal  pihysiological  activity  contrasts  very  sharply  with 
that  of  embryonic  vital  processes.  From  the  apparent  chaos  of  the 
germinal  globe  comes  the  oixlerly  arrangement  of  the  embryonic 
world.  Not  simple  increase  but  evolution  is  the  great  accomplish- 
ment of  the  life  of  the  embryo.  Not  at  once  either  is  the  evolution 
manifest  and  complete,  but  after  a  time  of  arrangement,  of  re-arrau,ue- 
ment,  and  of  remodelling,  and  through  a  series  of  changes  kaleido- 
scopic in  their  variety  and  in  the  rapidity  of  their  transposition. 
The  foetus  of  nine  or  ten  months  is,  although  greatly  enlarged, 
evidently  the  same  organisna  as  the  foetus  of  three  or  four  months. 
Put  a  magnifying  glass  over  the  latter,  and  you  may  <|uite  well 
imagine  that  you  are  looking  at  the  former.  Quite  otherwise  is  it 
with  the  emljryo.  What  dissimilarity  there  is  between  the  embryo 
of  forty  and  the  embryo  of  fourteen  days !  In  appearance,  what 
resemblance  can  be  seen  between  the  embryo  of  fourteen  days  and 
the  blastodermic  vesicle  ?  Trnly,  there  is  a  deep-seated,  a  funda- 
mental difference  between  the  results  of  vital  activities  in  the  fa'tus 
and  in  the  embryo.  At  the  same  time,  there  is  no  sharp  line  of 
division  between  the  two  periods ;  there  is  no  special  day,  far  less 
minute,  when  it  can  be  said  the  embryo  has  now  become  a  fwtus,  the 
time  of  modelling  is  past  and  that  of  growth  begun.  On  the  contrary, 
some  traces  of  the  peculiar  activities  of  the  embryo  continue  to  appear 
throughout  the  whole  foetal  epoch ;  and  growth  is  not,  of  course, 
alisent  in  the  embryonic  period.  Indeed,  there  is  a  sort  of  transition 
time,  the  neofretal,  and  to  that  it  will  be  well  to  direct  attention,  for 
it  has  a  very  evident  importance,  as  in  fact  all  transition  times  have. 


80 


ANTENAIAI.    I'AII  lOI.OC'i'    AM)    HYGIENE 


The   Neofcetal  Period. 

Just  as  postnatal  litV  lii-tiin.s  willi  a  iieiiiKl  of  tiaiisitiou  or  read- 
justment to  suit  new  environmental  conditions,  a  period  named  the 
neonatal ;  so  the  passage  from  embryonic  to  fcctal  life  is  marked  by 
a  transition  time  of  adaptation  {Natura  non  facit  saltus — Nature 
makes  no  leaps)  which  we  may  call  the  neofa'tal,  during  wliicli,  among 
other  notable  phenomena,  the  placental  economy  is  being  established. 
The  neofo-tal  period  coincides  roughly  (there  are  no  sharp  limits, 
Nature,  as  has  been  said,  making  no  leaps)  with  the  second  half  of 
second  (lunar)  month  of  intrauterine  life.  Its  commencement  is 
on  or  about  the  fortietli  day  (end  of  sixth  week),  when  the  new 
organism  takes  on  a  form  which  can  he  recognised  as  distinctly 
human ;  this  somewhat  indefinite  change  Minot  regards  as  marking 

tlie  end  of  the  emljryonic  epoch 
(Human  Embri/olof/i/,  p.  391, 
1892)  and  the  beginning  of  the 
fcetal.  It  is,  however,  better 
to  regard  it  as  marking  the 
beginning  of  a  jieriod  which 
is  neither  embryonic  nor  fcetal, 
but  a  transition  lietween  or 
combination  of  the  two  —  the 
organism  is  putting  off  its 
distinctively  embryonic  and 
putting  on  its  fcetal  characters, 
is  becoming  human,  i.e.  re- 
cognisably  similar  to  child  or 
adult.  The  "  transition  "  form 
is  seen  in  His'  enibryo  x.xxiv. 
(Dr.),  the  estimated  age  of  which  was  thirty-eight  days,  and  the  length 
of  which  from  neck-bend  to  coccygeal  bend  was  l"o  cm.  (Fig.  9). 
"  Transition  organism,"  we  may  call  it,  yet  it  is  probably  more 
correct  to  regard  organisms  of  all  ages  lietween  six  weeks  and  two 
months  as  transition  forms,  the  transition  itself  being  not  sudden, 
but  gradual,  recpiiring  two  weeks  at  least.  For,  during  the  seventh 
and  eighth  weeks  (neofcetal  period),  several  changes  take  place  in  the 
appearance  of  the  organism ;  and  some  of  these  can  lie  recognised  by 
comparing  the  His  embryo  (Fig.  9)  with  a  fcetus  (Fig.  10)  in  my 
collection,  measuring  2'5  cms.  in  length  (cephalo-coccygeal  length), 
and  of  an  estimated  age  of  fifty-six  days  (end  of  neofu>tal  period). 


Fig.  9. 


Fin.  10. 


Anatomy  and  Physiology  of  Neofcetal  Period. 

The  changes  which  occur  in  the  neofcetal  period  are  external  and 
internal ;  they  are  less  marked  than  those  which  have  occurred  in 
the  emltryo,  Init  they  are  much  more  marked  than  those  tliat  are  to 
occur  in  the  fa?tus. 

With  regard,  in  the  first  plarc,  to  crtenial  appearances,  the  following 
may  be  emphasised  a.s  noteworthy.     The  greater  part  of  the  head  of  the 


i 


NEOFCETAL   PKUIOD  81 

six  weeks'  embryo  is  sharply  flexed  at  right  angles  to  the  back  part  of  the 
head  and  neck,  so  that  the  eye  lies  in  front  of  the  ear  and  below  its  level. 
The  point  where  the  back  part  of  the  head  is  continuous  with  the  trunk  is 
marked  by  a  concavit\',  called  the  Nackengruhe.  In  the  fcetus  eight  weeks 
old,  elevation  of  the  greater  part  of  the  head  has  taken  place,  so  that  now 
the  mid-brain  lies  above  instead  of  anterior  to  the  hind  brain,  the  eye  lies 
in  front  of  the  ear,  but  more  nearly  at  the  same  level,  and  the  Narlcengruhe 
is  almost  obliterated.  In  the  six  weeks'  embryo  there  are  no  traces  of 
eyelids,  the  external  ear  is  scarcely  recognisable,  and  the  maxillary  processes 
have  little  more  than  united  in  the  median  line  anteriorly ;  in  the  eight 
weeks'  foetus  the  eyelids  are  present,  although  not  fully  formed,  the  concha 
is  quite  distinguishable,  the  anterior  fusion  of  the  maxillary  processes  is  com- 
plete, and  the  face  has  taken  on  the  human  appearance  (eyes,  nose,  mouth, 
chin).  In  the  six  weeks'  embryo  the  upper  limbs  (in  profile  views)  reach 
beyond  the  level  of  the  heart,  show  the  tripartite  division,  but  are  still 
strikingly  bud-like  :  in  the  eight  weeks'  fcetus  they  reach  beyond  the 
anterior  margin  of  the  chest  (in  profile  views),  show  clearly  their  three 
segments  and  five  separate  digits,  and  are  flexed  at  the  elbows  and  bent 
upwards  towards  the  face.  Similar  but  less  marked  changes  take  place  in 
the  lower  limbs.  The  anterior  contour  of  the  trunk  in  the  six  weeks' 
embryo  shows  very  evident  bulging,  due  to  the  presence  of  the  heart  and 
liver  :  this  character  is  not  so  noticeable  in  the  eight  weeks'  fo?tus,  although 
in  it  also  the  liver  is  of  "  relatively  enormous  dimensions,"  and  reaches  well 
into  the  hypogastric  region.  The  epidermis  at  the  end  of  the  first  month 
consists  of  two  layers,  and  this  two-lavered  stage  lasts  till  the  end  of  the 
neofoetal  period  ;  probably  the  outer  layer  of  cells  represents  the  epitri- 
chium.  The  dermis  is  not  yet  dift'erentiated  into  corium  and  subdermal 
laj'er ;  but  the  aniaf/e  of  the  mammar}'  gland  can  be  seen  at  the  eighth 
week.  The  caudal  projection  (true  tail),  which  attains  its  maximum  about 
the  thirty-fifth  day  (end  of  fifth  week),  becomes  less  and  less  marked  during 
the  neofoetal  period,  and  has  disappeared  as  a  free  appendage  at  the  end  of 
it  (attainment  of  "  human  "  form).  During  this  eventful  period,  also,  the 
protrusion  of  intestine  into  the  umbilical  cord  increases  to  reach  its  maxi- 
mum in  about  seven  and  a  half  weeks  :  the  genital  tubercle,  which  at  first  lies 
anterior  to  or  within  the  orifice  of  the  cloaca,  becomes  more  prominent, 
although  it  cannot  yet  be  distinguished  as  penis  or  clitoris.  Such  are  the 
external  changes  taking  place  in  the  organism  during  this  transition  time  of 
neofcetal  life,  those  most  noteworthy  being  the  elevation  of  the  head,  the 
disappearance  of  the  tail,  and  the  specialisation  of  the  face  and  limbs. 

The  internal  changes  are  no  less  wonderful  and  epoch-making.  They 
are  also  numerous,  and  call  for  some  kind  of  classification.  They  may  be 
conveniently  subdivided  into^(l)  the  more  marked  or  more  typically 
embryonic  changes,  and  (2)  the  less  marked  and  more  specially  fcetal 
changes.  In  the  former  group  I  place  the  changes  which  occur  in  the 
skeleton,  in  the  cranium  and  its  contents,  and  in  the  pelvis  and  lower 
part  of  the  abdomen  and  their  viscera.  In  the  latter  group  may  be  ranged 
the  changes,  slight  in  character,  which  take  place  in  the  organs  of  the 
thorax  and  upper  part  of  the  abdomen. 

1.  The  slcelefal  changes. — The  changes  which  occur  in  the  skeleton  are 
chiefly  of  the  nature  of  commencing  ossification.  Ossification  begins  in 
the  neofoetal  epoch,  to  end  far  on  in  post-natal  life — a  developmental 
change  late  of  appearance,  late  also  of  completion.  At  the  seventh  week 
ossific  nuclei  appear  in  the  clavicle  (first  bone,  then,  to  become  bone) ;  in 


8-'  ANTKNATAL    I'A  TIlOLOCiY    AND    IIVCIKNK 

the  shaft  of  ffiiuir  anil  of  tiliia  ;  in  tlie  frontal,  piirictal,  interparietal,  and, 
jierhaps,  in  the  sijuaniosal  and  palatine  bones  ;  in  tlic  bodies  of  the 
veitebrje,  at  any  rate  in  the  dorsal  region  ;  and  in  the  ribs  (in  this  week  or 
tlie  next).  In  the  eiglith  week  the  nuralier  of  ossific  nuclei  is  increased  by 
tlie  appearance  of  tliose  for  the  shafts  of  tlie  hnnierus,  radius,  and  fibida  ; 
for  the  nasals,  laclirymals,  vomer,  superior  niaxillaries,  and  malars  ;  for 
most  of  the  vertebrop  ;  and  possibly  also  for  the  metatarsals  and  meta- 
carpals. Ossification  then  has  made  a  commencement  at  the  end  of  tlie 
second  month  of  intrauterine  life.  The  rest  of  the  skeleton,  tliougli  not 
ossified,  is  already  definitely  mapped  out  in  cartilage  or  membrane,  e.g.  the 
skeletal  pieces  of  the  Hmbs.  It  is  noteworthy  tliat  the  sternum  consists  of 
two  cartilaginous  lateral  halves,  still  .separate  ;  and  that  the  neural  arches 
have  not  yet  met  on  the  ilorsal  side  of  the  spinal  cord.  The  condition  of 
the  spinal  cord  may  be  referred  to  here.  It  equals  in  length  the  vertebral 
column,  the  lumbar  and  cervical  enlargements  are  indicated,  the  central 
canal  begins  to  contract  towards  the  close  of  the  neofcetal  jjeriod,  and  the 
anterior  fissure  begins  to  appear  and  the  grey  matter  rapidly  to  increase. 
The  notochord  has  begun  to  disappear. 

2.  27(6  cepl/alir  clicaujes. — In  the  region  of  the  face  during  the  neofoetal 
period  there  are  noteworthy  changes.  The  nasal  processes  grow  to  form 
the  external  nose  ;  the  anlage  of  the  lachrymal  duct  is  present  at  the  sixth 
week  as  a  solid  ridge  ;  the  development  of  the  teeth  begins  with  the  formation 
of  the  dental  gmove  and  ridge  at  the  seventh  week,  and  the  liuddiiig  of  the 
enamel  organs  at  the  eighth  week.  The  anlage  of  the  submaxillary  gland  is 
present  at  the  beginning  of  neofoetal  life,  that  of  the  sublingual  appear  .soon 
after,  and  that  of  the  parotid  at  the  eighth  week  ;  about  the  same  time 
chondrification  of  the  larj'nx  begins.  Of  all  the  internal  changes  in  the 
head-end  of  the  foetus  at  this  time,  those  of  the  brain  are  of  most  importance. 
The  unequal  growth  of  the  various  parts  of  the  brain,  which  has  alreadj' 
led  to  the  production  of  mid-brain  flexure  and  neck-bend,  continues :  the 
wonderful  expansion  of  the  cerebral  hemispheres  makes  a  commencement, 
and  at  the  end  of  the  period  these  structures  have  expanded  to  the  edge  of 
the  mid-brain  ;  the  Sylvian  fissure  or  fossa  was  evident  at  the  fifth  week, 
marking  ott'  tlie  frontal  from  the  temporal  lobe,  and  in  addition  there  can 
now  be  seen  the  Bogenfurrhe  or  callosal  fi.ssure,  these  two  being  total 
grooves  or  true  folds  of  the  brain  ;  and  the  base  of  the  olfactory  lobe  is  carried 
forward  by  tliis  same  cerebral  hemispherical  expansion.  The  axes  of  the  eyes 
become  parallel  ;  and  there  is  fusion  of  some  of  the  tubercles  which  go  to 
form  the  external  ear.  There  are  already  indications  of  all  the  cranial  nerves, 
but  at  this  time  the  cavity  which  exists  in  the  optic  stalk  begins  to  close. 

3.  The  pelvic  changes. — At  the  opposite  or  pelvic  end  of  the  fcetus 
important  changes  are  also  taking  place.  The  WoltiSan  boily  reaches  its 
maximum  of  development  at  the  seventh  week,  and  at  the  eighth  begins  to 
resorb  ;  the  kidney,  which  measures  barely  '1  mms.  in  length  at  the  sixth 
week,  is  2 "5  mms.  at  the  end  of  the  neofoetal  period,  shows  commencing 
lobulation,  and  in  it  Malphigian  corpuscles  begin  to  form.  It  is  stated  that 
a  dilatation  of  the  allantois  to  constitute  the  urinary  bladder  takes  place,  but 
the  details  of  the  development  of  this  part  of  the  urino-genital  a]iparatus  have 
not  been  yet  ascertained.  The  testis  is  histologically  distinguishable  from 
the  ovary  at  the  sixth  week  by  the  smaller  number  of  Ureier  (primitive  ova  or 
ovic  cells)  in  it.  The  fusion  of  the  iliillerian  ducts  has  begun  at  the  eighth 
week.  Sex,  therefore,  is  already  recognisable  in  the  neofoetal  period, 
albeit  the  distinguishing  character  is  microscopical. 


NEOFGETAL   PERIOD  83 

i.  The  fltoraco-ahilominal  cJiamjes. — It  is  a  remarkable  fact  that  after 
the  sixth  week  of  intrauterine  life  the  organs  of  the  thorax  ami  upper 
part  of  the  abdomen  may  be  said  to  have  completed  their  development  : 
during  the  remaining  thirty-four  weeks  they  grow  indeed,  but  show  no 
changes  in  their  construction  till  birth  forces  new  functions  upon  them  ; 
some  of  them  do  not  change  even  then.  This  is  specially  true  of  the  heart 
and  great  vessels,  for  they  change  little,  if  at  all,  between  the  beginning  of 
the  neofoetal  and  the  end  of  the  foetal  period.  In  the  circulating  blood 
red  cells  (nucleated)  are  the  most  ntimerous,  but  the  red  plastids  (non- 
nucleated)  have  begun  to  appear.  The  liver  also  is  well  developed, 
and  grows  enormously  in  size  in  the  second  month,  and  the  gall- 
blailder  is  present.  The  spleen  is  quite  recognisable.  There  is  a 
slight  change  in  the  pancreas,  but  in  its  position  onlj^ ;  it  lies  at  first 
parallel  to  the  long  axis  of  the  body,  and  later  comes  to  be  directed  trans- 
versely. The  asymmetry  of  the  lungs  is  seen  even  at  six  weeks,  and  the 
lobes  are  marked  off  as  branches.  The  typical  form  of  the  stomach  is 
indicated  at  the  fifth  week,  before,  therefore,  the  beginning  of  the  neofcetal 
epoch  ;  and  the  villi  and  glands  of  the  intestine  have  begun  to  develop  at 
the  second  month,  although  the  intestinal  coils  continue  to  elongate  during 
foetal  life,  and  may  not  have  taken  up  their  permanent  position  and 
relations  even  at  the  time  of  birth.  The  development  of  the  thymus  gland 
from  the  entoderm  of  the  third  gill-cleft  has  begun.  The  two  lateral 
anlarjes  of  the  thyroid  gland  have  united  with  the  single  median  anlcuje  at 
the  seventh  week ;  tlie  ductus  thyreoglossus  may  remain  open  till  the 
eighth  week  ;  and  at  the  same  time  the  formation  of  hollow  acini  has  com- 
■menced.  lu  oiie  detail,  however,  development  in  this  region  is  incomplete  : 
the  separation  between  tlie  pleural  and  abdominal  cavities  has  not  taken  place 
in  a  two  months'  fostus. 

Xot  only  are  there  changes,  external  and  internal,  in  the  embryo-foetus 
during  the  neofoetal  period,  but  there  are  also  alterations  in  the  foetal  append- 
ages of  very  considerable  importance.  The  organism  lies  in  the  sac  formed  by 
the  decidual  membranes,  the  reflexa  being  still  distinct  from  the  vera  ;  the 
chorion  is  villous  all  over,  but  the  villi  in  the  region  where  the  placenta  is 
soon  to  form  are  larger  than  the  others,  and  are  already  vascularised  to  a 
greater  degree  by  the  allantoic  or  umbilical  vessels  ;  the  decidual  membranes 
and  chorion  weigh  together  from  11  to  1-5  grms.;  the  liquor  amnii  is  pre- 
sent in  the  amniotic  cavity  to  the  amount  of  10  to  13  grms.;  the  umbilical 
vesicle  has  atrophietl,  but  is  still  to  be  seen  attached  to  the  abdomen  of 
the  neofoetus  by  a  thin  cord,  and  doubtless  there  is  still  some  circulation 
going  on  in  the  vitelline  or  omphalo-mesenteric  vessels.  As  has  been 
already  stated,  the  projection  of  intestine  into  the  umbilical  cord  is 
increased  during  the  first  week  of  the  neofcetal  period.  The  great  changes 
seen  in  the  environment  of  the  foetus  at  this  epoch  are  the  replacement  of  the 
vitelline  by  the  allantoic  or  umbilical  circulation,  and  the  progressive  growth 
in  importance  of  the  placental  over  the  general  chorionic  circulation. 

The  end  of  the  ueofoetal  period  therefore  coiucides  with  the 
beginning  of  the  placental  connections.  There  is  thus  a  sort  of  birth 
before  birth,  a  transition  not  so  sharp  as  that  which  occurs  at  the 
tenth  month  of  intrauterine  life,  but  nevertheless  definite  enough 
and  of  great  importance.  Further,  just  as  there  are  many  traces  of 
the  foetus  to  be  seen  iu  the  new-born  infant,  so  in  the  neofcctus  there 
are  not  a  few  indications  of  the  embryo ;  there  are  in  it  still  some 


84      ANTENATAL  I'ATHOl.OCY  AND  I1Y(;IKNK 

signs  of  typical  eiiihiyoiiic  or  devolopiuenlul  acliviLy,  as  tlie  ]ire- 
cediug  paragiaplis  abumlaiitly  have  demonstiated.  ]iy  the  end  of 
tiie  third  month,  as  will  he  seen,  tlie  new-horn  fo'tus  is  fairly  estah- 
lished  under  the  jilacental  n'ginie,  its  yolk-sac  (vitelline)  connections 
can  be  dispensed  with  and  all  its  circulatory  activities  can  he  con- 
centrated in  the  allantoidal  union  with  the  decidua  serotina.  The 
transition  thus  accomplished  is  not  without  its  element  of  danger; 
and  just  as  the  neonatal  period  is  commonly  one  of  danger  to  the 
new-horn  infant,  so  the  neofcetal  is  full  of  risk  to  the  "  new-horn 
fa>tus."  It  is,  at  any  rate,  a  fact  well  known  that  intrauterine  life 
is  often  brought  to  an  untimely  end  liy  abortion  at  the  third  month. 
The  incidence  of  abortion  so  immediately  after  the  neofo'tal  period 
suggests  want  of  eomiilete  adajitation  tn  the  new  condition  of  life,  in 
other  words,  a  defective  establishment  of  the  placental  cunnections. 

Fcetal  Growth  and  Development. 

Such  being  the  characters  of  the  neofcetus,  it  remains  for  us  to 
trace  the  stages  through  which  the  organism  passes  in  order  to  become 
a  neonatus  ;  in  other  words,  it  is  necessary  for  us  to  possess  some  know- 
ledge of  the  changes  which  occur  month  by  month  in  the  growth  and 
development  of  the  fcetus  from  the  eighth  to  the  fortieth  week  of 
intrauterine  life.  It  is  essential  that  we  have  some  idea  of  the  body, 
the  diseases  of  which  we  are  preparing  to  study ;  that  is,  if  we  wish 
in  any  measure  to  make  progress  in  our  knowledge.  Dry  details, 
(lou].)tless,  but  peculiarly  essential.  Details  which  the  reader  skimming 
lightly  over  the  surface  of  the  subject  will  pass  by.  Let  them  he  put 
in  small  type  to  warn  off  such  readers ;  let  them  also  be  compressed 
within  reasonable  limits.  Perchance  a  reader  here  and  there  will 
read,  and  remember,  and  even  form  visual  images  of  the  IVetus 
at  the  different  months.  Unfortunately  for  him  and  for  Antenatal 
Pathology,  only  glimpses  of  antenatal  life  are  yet  possible :  it  is  not 
practicable,  through  imperfect  knowledge,  to  give  a  cinematographic 
procession  of  fietal  forms  at  different  stages  and  of  dih'erent  ages. 

Third  Month. 

The  third  month  of  intrauterine  life  is,  let  it  he  borne  in  mind,  the  first 
mouth  of  typically  foetal  life.  In  it,  a.s  in  all  the  months  that  follow  it, 
there  are  changes  to  he  recorded:  changes  which  may  be  grouitcd  into 
external,  internal,  and  environmental.     These  may  be  taken  in  order. 

The  foetus  by  the  end  of  the  month  measures  from  7  to  9  cms.  in  length, 
and  weighs  30  grms.  (460  grs.).  The  iirntruding  abdnmcn  has  receded.  At 
the  ninth  week  two  lines  are  very  evident  nn  the  face,  one  from  the  eye  to 
the  angle  of  the  mouth,  the  other  passing  down  alongside  of  the  nose  ;  the 
external  nares  are  closed  with  a  jihig  of  epithelium,  wliich  disappears  later 
(at  the  fifth  month).  The  eyes  are  now  jn'otected  by  eyelids,  ami  the  mouth 
is  closed  by  lips;  if  the  mouth  be  opened  it  can  be  seen  that  the  shutting 
off  of  the  buccal  from  the  nasal  cavity  has  begun  in  this  month  and  is 
finished  at  the  end  of  it,  when  also  the  uvula  has  appeared.  In  the  ex- 
ternal ear  the  upper  and  posterior  part  of  the  concha  bends  forward  so  as  to 


FCETUS   AT  THIRD   MONTH  85 

cover  the  anthelix  :  this  stage  of  anteversiou  of  the  ear  has  a  short  duration 
of  possibly  a  fortnight.  The  toes  as  well  as  the  fingers  are  now  separate. 
In  this  month  there  is  the  first  indication  of  nails,  as  tliickenings  of  the 
epitrichiuni  over  the  end  of  the  digits ;  but  the  primary  terminal  position 
of  the  thickened  epitrichiuni  ("eponychium,"  Unna)  is  quite  transitory,  and 
soon  "  the  ungual  area  migrates  to  the  dorsal  side  of  the  digit "  (!Minot,  op. 
cii.,  p.  554),  througli  growth  and  expansion  of  the  palmar  side.  The 
epidermis  at  this  age  has  reached  the  "  several-layered  stage  " ;  there  is  a 
basal  layer  of  cuboidal  cells,  then  two  or  three  rows  of  irregular  large  cells, 
and  an  outer  epitrichial  layer  of  distinctive  "  dome  "  cells.  On  parts  which 
are  to  be  hairy  the  epitrichiuni  does  not  advance  beyond  this  stage,  but  on 
hairless  parts  it  persists  as  several  layers.  Later,  it  is  probable  that  the 
epitrichiuni  undergoes  cornification,  becoming  the  stratum  corneum  or  liorny 
layer,  while  the  stratum  lucidum  has  become  difierentiated  and  is  continuous 
at  the  ends  of  the  digits  with  the  nails.  The  dermis  shows  two  layers  at 
the  third  month  :  (1)  A  true  dermal  layer  or  corium,  and  (2)  a  subdermal 
stratum.  Hair  anlage-i  appear  at  this  time  over  the  foreliead  and  eyebrows. 
At  the  pelvic  end  of  the  ten  weeks'  foetus  the  genital  tubercle  is  prominent, 
and  on  each  side  of  it  is  a  "  genital  labium  "  ;  later  (in  the  fourth  month), 
the  genital  labia  unite  to  form  tlie  scrotum  in  the  male,  or  remain  separate 
to  constitute  the  labia  majora  of  the  female.  It  is  hardly  possible  at  the 
end  of  the  third  month  to  tell  the  sex  of  the  foetus  from  the  inspection  of 
the  external  genitals,  but  sometimes  in  the  male  the  urethral  groove  in  the 
genital  tubercle  has  closed,  and  then  it  can  be  said  that  the  distinctive  stage 
of  the  penis  as  compared  with  the  clitoris  has  been  attained.  Finally,  with 
regard  to  these  external  characters  and  changes,  it  has  to  be  noted  that  by 
a  mechanism,  the  nature  of  which  is  at  present  unknown,  the  loop  of 
intestine  in  the  root  of  the  umbilical  cord  is  retracted  within  the  abdomen. 

The  internal  changes  during  the  third  month  are,  like  those  in  the 
neofcetal  perioil,  of  very  considerable  importance.  In  respect,  in  the  first 
place,  to  the  skeleton,  it  is  to  be  noted  that  the  neural  arches  have  met 
posteriorly  in  the  dorsal,  but  not  yet  in  the  lumbar  and  sacral  regions  of 
the  spine.  In  addition  to  the  ossific  nuclei  which  have  already  apjieared, 
deposits  of  bone  have  to  be  recorded  in  the  ulna,  phalanges,  prsemaxillaries, 
tympanals,  iliinn,  ischium,  occipital  and  sphenoidal  regions  of  the  cranium,  in 
the  mandible,  and  also  in  the  lower  end  of  ^Meckel's  cartilage  which  is  in- 
corporated in  tlie  mandible.  By  the  end  of  the  third  month,  the  joints  of 
the  limbs  are  true  articulating  surfaces,  having  passed  at  this  early  date  out 
of  the  synarthrodia!  stage  ;  the  articulating  surfaces  are  therefore  shaped 
before  any  free  motion  can  begin.  In  the  spinal  cord  the  contraction  of  the 
central  canal  continues  till,  at  the  tenth  week,  the  walls  have  met  everywhere 
except  at  the  dorsal  part ;  the  cords  of  Durdach  have  arisen,  the  anterior  and 
posterior  horns  of  grey  matter  are  of  equal  size  and  of  the  same  shape,  and 
are  connected  by  a  broad  band  ;  the  cord  itself  is  still  as  long  as  the  spine, 
and  its  cervical  and  lumbar  enlargements  are  quite  well  developed.  In  the 
brain  the  aidages  of  the  cerebellar  hemispheres  and  vermis  are  recognis- 
able, ami  the  characteristic  transverse  fibres  of  the  pons  Varolii  liave 
appeared  as  a  narrow,  thin  band  ;  the  raid-brain,  which  has  had  a  precocious 
expansion,  continues  to  grow,  but  at  a  much  slower  rate,  and  at  the  third 
month  the  cerebral  peduncles  are  just  recognisable;  in  the  fore-brain,  the 
anlages  of  the  septum  lucidum,  corpus  callosum,  fornix,  and  anterior 
commissure  are  well  seen  ;  the  cerebral  hemispheres  continue  their  remark- 
able expansion,  and  now  cover  fully  one-half  of  the  mid-brain  (the  stage 


SG  ANTl'.NATAL    I'AlHOLOCiY    AND    HVCilllNK 

of  (levelo]imcnt  wliicli  is  pi^nnaiieiil  in  reptiles);  the  Sylvian  fossa  begins 
to  deepen  int"  a  tissnre,  and  the  Bogenfitrche  is  now  well  marked  :  and  a 
iliflerentiatiiiiymd  forward  bending  of  the  olfactory  lobe  takes  place.  In 
the  eye,  atr^^^Mif  the  arteria  centralis  and  of  its  branches  begins,  folds 
appear  on  the  n^ffibiie  to  its  rapid  growth,  and  the  lachrymal  gland  can 
1)6  recognised  in  a  soua  state.  The  tymjianic  cavity  is  very  small.  Further 
dcveloimient  takes  place  in  connection  with  the  dental  germs  of  the  milk 
teeth,  and  the  follicular  w-all  ajipears. 

There  are  changes  at  the  jielvie  end  of  the  fa-tus  during  the  third 
month.  The  testis  can  now  lie  distinguishe(l  from  the  ovary  by  its  external 
form  ;  its  descent  begins  about  the  tenth  week,  and  is  due  in  the  first 
instance,  at  any  rate,  to  atrophy  of  the  i)art  of  the  uro-genital  ridge  lying 
taihvard  of  the  sexual  gland.  The  resorption  of  the  Wolftian  body  con- 
tinues, but  traces  of  the  glomeruli  can  usually  be  made  out  till  the  end  of 
the  month.  The  fusion  of  the  ^Miillerian  ducts  to  form  the  uterus  is 
generally  complete  at  this  time,  so  that  the  sex  can  now  be  determined  by 
the  presence  or  absence  of  that  structure. 

The  thoraco-abdominal  changes  are  comparatively  unimportant.  The 
heart  shows  little  alteration  ;  but  the  blood  is  now  mainly  made  up  of  red 
plastids  (non-nucleated),  and  nucleated  red  cells  form  a  small  minority.  The 
lumen  of  the  anlaije  of  tlie  thymus  is  obliterated  about  the  twelfth  week ;  in 
the  thyroid  the  formation  of  hollow  acini  is  continued.  The  changes  in  the 
stomach  consist  in  the  development  of  the  peptic  and  mucous  glands,  and  in 
the  appearance  of  prominences  between  the  gland  openings,  which  have  been 
called  villi,  but  are  not  truly  so.  In  tiie  liver  (which  is  very  large,  extending 
into  the  hypogastric  region)  the  vascular  territories  of  the  portal  ami  hepatic 
veins  are  distinguishable ;  and  islands  of  tissue  appear,  each  of  which  is  the 
anlage  of  a  group  of  lobules  ;  the  j)ortal  system  cuts  into  these  islands  and  so 
forms  the  lobules.  The  suprarenal  glands  assume  the  cap-shape  at  this  time, 
and  clusters  of  cells  (symi)athetic  part?)  can  be  recognised  in  them,  but  only 
during  the  third  month.  ]!oth  the  kidneys  and  the  suprarenals  show  rapid 
growth,  with  the  result  that  they  are  brought  into  contact,  the  adrenal  rest- 
ing upon  the  kidney.  The  diaphragmatic  .separation  of  pleural  from  the 
peritoneal  cavity  has  now  completelv  taken  place. — {Mall  in  Hookfr's  article, 
Airh.  Perliat.,  xiv.  649,  1897.) 

The  foetal  environment  has  altered  little  at  this  month.  The  decidua 
reflexa  diminishes  in  thickness  and  shows  marked  degenerative  changes — 
presence  of  a  hyaline  substance,  fibrin  so  called,  and  vagueness  of  the 
cellular  outlines.  The  chorionic  villi  are  limited  to  the  part  in  connection 
with  the  decidua  serotina,  wliere,  now,  the  small  placenta  (weight,  23  J  grms.) 
is  quite  distinct.  The  whole  decidual  sac  with  its  ovular  contents  is  about 
the  size  of  "a  goose's  egg"  ;  more  exactly,  its  length  is  from  'J'5  to  11  cms. 
The  umbilical  cord  is  from  7  to  12  cms.  long,  shows  some  degree  of  torsion, 
and  has  the  umbilical  vesicle  attached  to  it  at  its  placental  end  by  the  yolk- 
stalk  ;  the  rest  of  the  yolk-stalk  is  embedded  in  the  cord.  The  amount  of 
liquor  amnii  is  about  42  grms. 

FofRTH  ^loxTH. 

During  the  fourth  month  of  intrauterine  or  the  second  month  of  foetal 
life  (13  to  IG  weeks)  the  fo'tus  has  a  length  of  from  10  to  17  cms.,  and  a 
weight  of  about  55  grms.  (850  gr.s.).  Some  hairs  are  to  be  seen  on  the 
scalp,  and  over  the  body  the  fine  down  (lanugo)  is  beginning  to  sprout  forth. 


FCETUS   AT   FOURTH    MONTH  87 

^licroscopic  sections  of  the  .skin  sliiiw  riilges  on  the  umler  side  of  the 
epidermis,  and  the  appearance  of  fat  cells  in  the  subdermal  tissue  ( 1  -1  weeks). 
Slight  changes  take  place  in  the  external  ear ;  the  tultercnlum  anterior 
encroaches  npon  the  fossa  angularis,  and  reduces  the  lowe^^pt  of  it  to  a 
fissure,  and  so  the  tuberculum  itself  comes  almost  h^^^lmact  with  the 
anthelix  and  the  anti-tragus  ;  through  the  growth  of  ^Htlge  the  upper  part 
of  the  fossa  is  separated  from  the  lower,  and  the  latter  becomes  the  opening 
of  the  meatus ;  and  later  (in  the  fifth  month)  the  lobule  is  marked  oft'  as 
the  tienia  lobularis.  The  eyelids  are  now  fully  united.  An  inspection  of 
the  posterior  end  of  the  fcetus  is  at  this  month  sufficient  to  determine  the 
sex  of  the  oti'spring,  as  the  scrotum  in  the  male  is  evident. 

The  internal  changes  which  occur  in  the  fourth  month  are  important, 
although  not  so  extensive  as  those  iif  the  third.  With  respect,  in  the  first 
place,  to  the  development  of  the  skeleton,  the  scapula  is  one-half  cssified  at 
this  age;  ossification  has  begun  in  the  pterygoids,  although  these  do  not 
unite  with  the  alisphenoids  till  the  fifth  or  even  the  sixth  month  ;  the  centres 
for  the  body  and  odontoid  [irocess  of  the  axis  vertebra  appear  in  this  or  in 
the  next  month  ;  a  point  of  ossification  can  be  seen  in  the  asceniling  ramus 
of  the  pubis  ;  the  neural  arches  have  closed  throughout  the  whole  length  of 
the  spinal  column ;  and,  according  to  Professor  Arthur  Thomson  {Joiirn. 
Anat.  ami  P/ii/sioL,  xxxiii.  359,  1899)  the  sexual  differences  of  the  pelvis 
are  already  indicated.  The  ossification  of  the  cranial  bones  is  proceeding, 
but  the  spaces  between  them  are  still  widely  open.  In  the  brain  it  is  to  be 
noted  that  there  is  a  rapid  increase  of  the  ]ions  Varolii,  that  transverse 
grooves  appear  upon  the  cerebellum,  that  a  rapid  growth  of  the  choroid 
plexus  takes  ])lace  which  quite  fills  the  lateral  ventricle,  and  that  the  corpora 
albicantia  can  be  seen  on  the  floor  of  the  third  ventricle.  The  cerebral  hemi- 
spheres cover  nearly  the  whole  of  the  mid-brain.  The  Sylvian  fissure 
becomes  deeper,  and  at  the  posterior  end  of  the  Bogenfuirhe  appear  the 
aniages  of  the  parieto-occipital  and  calcarine  fissures,  diverging  to  form  the 
future  cuneate  lobe.  In  this  month,  also,  the  cartilage  of  the  Eustachian 
tube  can  be  recognised  ;  the  enamel  organ  of  the  milk  teeth  is  fullj^  differ- 
entiated about  the  fifteenth  week  ;  and  a  commencement  is  made  with  the 
<levelopment  of  the  tonsils  in  the  shallow  pouch  representing  the  second 
gill-cleft  behind  the  arcus  palato-glossus  (Gulland,  Lahorat.  Rep.  R.  C.  Phys. 
Edin.,  iii.  163,  1891).  The  trachea  shows  the  high  cylinder  epithelium 
which  remains  throughout  life.  At  the  pelvic  end  of  the  fcetus  the  division 
of  the  cloaca  into  uro-genital  and  anal  openings  has  taken  place  (14  weeks) ; 
the  evagination  which  is  to  form  the  prostate  and  that  which  is  to  give  rise 
to  Bartholin's  gland  can  be  recognised ;  and  the  testis  has  its  permanent 
form,  but  the  sexual  cords  in  it  remain  solid  throughout  foetal  life.  The 
conversion  of  the  hind  remnant  of  the  genital  fold  into  the  gul  lernaculum  is 
going  on,  but  is  not  completed  during  the  fiiurth  month.  In  the  female, 
the  lumen  of  the  vagina  is  closed.  The  kidneys  show  well-marked  Henle's 
loops.  The  musculature  of  the  stomach  is  clearly  evident  at  this  time  in 
intrauterine  life. 

With  regaril  to  the  foetal  environment,  it  is  tci  be  mited  that  the  decidua 
reflexa  is  in  contact  with  the  vera,  and  exhibits  still  further  signs  nf 
coagulation-necrosis  antecedent  to  its  disintegration  and  removal,  for  it  is 
probable  that  !Minot  {op.  rit.,  p.  20)  is  right  in  thinking  that  there  is  no 
fusion  but  a  complete  disappearance  of  the  reflexa.  The  meaning  of  the 
phenomenon  is  not  clear;  "as  to  the  purpose  or  advantage  of  the  sacrifices 
of  maternal  tissue  we  are  in  the  dark,"  says  Minot  {op.  cif.,  p.  21);  in  the 


UNIVERSITY 

OF 


88  ANTKNATAL    I'A  rH()L()(;Y    AND    HV(iIKNE 

(lurk,  truly,  :il]nut  tlu'sc  and  many  ntlicr  tilings  in  anti-natal  lift',  but 
licginninf;  tn  sit  a  pin-imint  nf  light  here  and  there.  The  placenta  has 
increased  in  size  in  tlie  fnurth  ninnth,  and  weighs  from  ."^O  tn  50  grnis. ;  the 
liquor  amnii^kdis  00  grms.  ;  so  that  the  foetus  now  weighs  a  little  more 
than  the  placfflWIl^id  a  little  less  than  the  liquor  amnii.  The  mnhilieal 
cord  shows  a  rertaii^liKiunt  of  twisting;  in  it  tlie  cadom  is  nearly  or  quite 
ohliterateil  ;  the  vitelline  duct  remains  till  the  sixtli  month  ;  and  the  now 
solidified  allanti  lie  duct  may  persist  till  the  full  term.  The  external  cover- 
ing of  the  cord  exhibits  a  double  layer  of  ectodermic  cells,  the  outer  stratum 
of  which  may  possibly  l)e  the  representative  of  the  epitrichium,  at  any  rate, 
some  of  its  cells  are  (hime-shaped.  The  lengtli  of  tlie  cord  will  be  about 
19  cms.  (Hecker).  The  foetus,  if  expelled  from  the  uterus  at  this  mimtli, 
may  live  for  some  hours;  and  at  this  time  its  limbs  may  show  vital 
tremblings  and  twitchings. 

The  chief  clianges  found  in  the  foetus  at  the  fourth  month  are  still 
situated  at  its  two  extremities  (cephalic  and  pelvic)  and  in  tlie  skeleton. 
The  developmental  or  embryonic  changes  are  fewer  now  than  previously, 
and  affect  particularly  the  external  ear,  the  brain,  and  the  genital  organs. 
Ossification  is  actively  proceeding.  Foetal  growth  in  size  and  weight  is 
wonderfully  rapid. 

Fifth  Month. 

In  the  fifth  month  (third  of  foetal  life)  the  same  rapid  growth  is  con- 
tinued ;  the  foetus  measures  from  18  to  27  cms.  in  lengtli,  and  weighs 
about  273  grms.  (8  oz.).  The  face  and  body  of  the  foetus  have  a  wrinkled 
appearance,  "  senile  "  look,  a  character  to  be  ascribed  to  the  small  quantity 
of  subcutaneous  adipose  tissue  which  is  as  yet  present.  At  the  same  time, 
the  subdermal  fat  is  increasing,  and  can  be  seen  in  little  whitish  islands  in 
sections  of  the  skin.  The  cells  of  the  epitrichium  are  very  large,  much 
larger  than  those  of  the  subjacent  layers.  Xear  the  beginning  of  the  fifth 
month  hairs  have  appeared  over  the  whole  head,  and  by  the  end  of  the 
month  (twentieth  week)  practically  all  the  hair  areas  have  been  mapjied 
out  all  over  the  body.  The  nails  are  becoming  more  horizontal  and  less 
oblique  in  relation  to  the  dermis.  Sebaceous  glands  begin  to  ajipear  on 
the  head  at. this  time,  and  by  the  end  of  the  month  they  are  plentiful 
there  and  elsewhere,  with  the  result  that  traces  of  the  vernix  caseosa  are  to 
be  seen.  Sudoriparous  glands  also  make  their  first  appearance,  but  have  as 
yet  no  lumen,  and  consequently  no  secretion.  The  eyelids  begin  to  show 
signs  of  separation.  "Wax  glands  are  developed  in  connection  with  the 
external  auditory  meatus.     The  hymen  is  differentiated. 

The  internal  changes  consist,  in  the  first  place,  in  the  extension  of  the 
jirocess  of  ossification,  thus  the  osseous  centres  of  the  vertebral  bodies  reach 
the  surface  of  the  cartilage  during  this  month,  and  several  of  the  bones  of 
the  cranium  take  on  their  more  permanent  form.  In  the  second  place,  the 
brain  shows  further  developmental  changes :  the  cerebral  hemispheres 
now  cover  not  only  the  thalameiicephalou  and  mesencephalon,  but  also  the 
cerebellum  and  medulla  ;  the  fissure  of  Sylvius  has  become  deeper  and  more 
oblique,  but  still  leaves  the  island  of  Eeil  ex]iosed  to  view  ;  the  fissure  of 
Rolando  is  sometimes  found  during  this  month,  and  the  colloso-marginal  or 
splenial  fissure  is  generally  recognisable,  marking  off  the  gyrus  fornicatus  ; 
and  the  corpora  quadrigemina  on  the  dorsal  wall  of  the  mid-brain  are 
marked  off  by  oblique  grooves.  At  this  time  in  intrauterine  life  the  siiiiial 
cord  has  greatly  grown  ;  but  the  central  ciinal  is  now  relatively  small,  for  it 


I 


I 


FCETL'S   AT   SIXTH    MONTH  89 

is  strttionary.  In  the  cerebellum  the  cells  of  I'urkinje  are  recognisable  ;  the 
cerebral  peduncles  begin  markedly  to  enlarge,  an  enlargement  due  in  great 
part  to  their  penetration  by  the  pyramids  of  the  medulla  oblongata.  In  the 
third  i)lace,  further  chauges  occur  in  the  developing  teeth  jn  the  jaw  ;  in 
the  case  of  the  milk  teeth  the  follicle  closes  above  the  gfrm,  the  neck  of 
the  enamel  organ  is  resorbed,  and  dentine  appears ;  wlfile  the  enamel  buds 
of  the  permanent  teeth  can  be  recognised  (the  enamel  bud  of  the  first 
molar,  it  may  be  noted,  was  seen  earlier,  at  the  fifteenth  week).  In  the 
fourth  place,  some  minor  changes  occur  in  the  abdominal  and  thoracic 
viscera ;  the  development  of  the  vagina  (in  the  female)  continues ;  the 
jiaucreas  loses  the  mesentery  which  it  has  till  this  time  possessed,  and  with 
it  its  movability ;  in  the  omentum  the  «?i/a(/es  of  lymphatics  and-fat  cells 
are  recognisable  ;  and  in  the  heart  the  chordse  tendinese  apjiear. 

The  foetal  environment  now  shows  more  than  ever  the  predominance  of 
the  placenta  (Fig.  13),  which  weighs  from  12-5  to  300  grms.  (178  grms., 
Hecker).  The  umbilical  cord  measures  about  31  cms.  in  length ;  and  the 
weight  of  the  liquor  amnii  generally  exceeds  that  of  the  foetus  at  this  date. 
The  foetus  is  now  capable  of  making  movements  which  can  be  easily 
recognised  by  the  mother  as  indications  of  the  life  of  her  unborn  child, 
"  quickening  "  as  the  phenomenon  is  called.  If  born  alive,  the  infant  may 
make  some  respiratory  etibrts,  and  may  even  survive  for  some  hours. 

Sixth  Month. 

During  this  month  there  is  a  further  slackening  in  developmental 
changes,  but  the  extraordinarily  rapid  growtli  in  size  and  weight  continues, 
so  that  now  the  foetus  measures  from  28  to  34  cms.  in  length  (Fig.  11), 
and  weighs  676  grms.  (23i  oz.).  The  length  in  the  preceding  month  was, 
as  will  be  remembered,  18  to  27  cms.,  and  the  weight  273  grms.  or  8  oz. 
(Fig.  12).  There  is  more  hair  on  the  head,  and  eyebrows  and  eyelashes 
can  be  recognised ;  the  lanugo  ("  that  ancestral  simian  characteristic ")  is 
still  present  in  large  amount,  and  doubtless  in  this,  as  in  other  later  months, 
much  hair  is  shed  into  the  liquor  amnii.  The  skin  is  still  somewhat 
wrinkled  ("  senile  "),  but  a  greater  amount  of  fat  is  being  deposited  in  the 
subcutaneous  tissue.  The  free  margin  of  the  nails  still  projects  from  tlje 
tmderlying  skin  (persistence  of  ungual  obliquity).  The  vernix  caseosa, 
consisting  of  sebaceous  secretion,  hairs,  and  epidermic  cells,  is  now  conspicu- 
ously present.  In  the  case  of  the  skin  of  the  hands  and  feet,  the  papillfe 
of  the  dermis  are  well  marked. 

There  are  in  this  month  internal  changes  which  are  again,  as  in  pre- 
vious months,  largely  located  in  the  skeleton,  in  the  brain,  and  in  the 
pelvic  end  of  the  fcetus.  Ossific  nuclei  now  appear  in  the  os  calcis,  in  the 
presternum,  and  in  the  first  piece  of  the  meso-sternum  (Paterson,  Journ. 
Anat.  and  Physiol.,  xxxv.  21,  1900).  The  marking-off  of  the  cerebral 
convolutions  continues  :  there  can,  at  this  time,  be  quite  well  seen  the 
fissure  of  Rolando  ;  the  preecentral  fissure  of  the  frontal  lobe  ;  the  intra- 
parietal  of  the  parietal  lobe  ;  the  superior,  inferior,  and  occipito-temporal 
fissures  of  the  temporal  lobe  ;  and  tlie  post-central  fissure  of  the  island  of 
Reil.  An  angular  notch  is  noticeable  in  the  anterior  margin  of  the  fissure 
of  Sylvius.  At  this  age  the  arteria  centralis  of  the  eye  and  most  of  its 
branches  have  aborted  ;  and  the  development  of  the  definite  form  of  the 
internal  ear  is  complete. 

At  the  posterior  end  of  the  foetus  the  chief  change  is  found  in  the 


90  ANTKNATAI.    l'Aril()I.()(;Y    AND    HVCIENK 

descent  of  the  testicle.  At  tlir  I'lul  of  thr  mcinlli  the  male  sexual 
gland  lies  opposite  the  internal  inguinal  ring.  This  descent  is  the 
last  great  alteration  in  the  relation  of  organs  to  occur  in  ante- 
natal life,  and  it  occurs  only  in  the  male,  although  there  is  a  less 
marked  downward  movement  of  the  ovary  in  the  female  fa'tus.  Aboiit 
the  exact  mechanism  of  the  descensus  lestindm'tun  conflicting  statements 
have  been  made  and  )nuch  mystery  ha.s  existed.  It  lias  to  be  borne  in 
mind,  however,  that  most  of  the  relation-changes  which  occur  in  intra- 
uterine life  are  due  to  differences  in  growtli  or  develo]iment  of  contiguous 
parts;  one  organ  or  part  grows  in  size,  that  next  to  it  diminishes  or 
atrophies  ;  or  one  organ  grows  or  atrophies  at  a  faster  rate  than  its  neigh- 
bour;  and  so  one  organ  may  pass  by  or  overlap  or  take  the  place  of  another 
in  the  kaleidoscopic  life  of  the  unborn  infant.  Some  jirocess  .sucli  as  this 
brings  the  testis  from  its  first  position  down  to  the  level  of  the  internal 
inguinal  ring.  As  will  be  remembered,  tlie  descent  has  already  begun  at 
the  second  month  with  the  nearly  complete  disappearance  of  tlie  uro- 
genital fold  lying  taihvard  of  the  testis;  the  remnant  of  this  fold  is  con- 
verted into  the  gubernaculum,  a  change  occupying  from  the  fourth  to  the 
sixth  month;  at  first  the  growth  of  the  gubernaculum  causes  the  testicle  to 
move  forward,  and,  afterwards,  its  atrophy  accounts  for  the  passage  of  the 
gland  along  the  wall  of  the  processus  vaginalis  (which  is  due  to  an  evagina- 
tion  of  the  peritoneum  at  the  inguinal  ring).  This  stage  in  testicular 
descent  is  that  which  is  permanent  in  some  rodents  and  other  mammals  : 
the  further  descent  (into  the  scrotum)  is  late  of  occurrence  in  the  liuman 
foetus,  late  also  of  occurrence  in  the  zoological  series,  being  high  up  in 
the  ]\Iammalia. 

In  the  abdominal  cavity  the  liver  is  still  disproportionately  large  com- 
pared with  the  other  organs  ;  but  these  other  viscera  are  now  beginning  to 
overtake  the  liver,  the  growth  of  which  is  slackening.  The  appendix 
vermiformis  of  the  intestine  is  long,  slender,  and  relatively  better  developed 
than  in  the  adult  ;  four  well-marked  ridges  of  mucous  menilirane  can  be 
recognised  in  the  oesophagus  ;  and  in  the  trachea  the  glands  and  cartilages 
are  clearly  developed. 

The  placenta  weighs  from  22.5  to  4.55  grms.  (273  grms.,  Hecker). 
and  the  cord  measures  37  cms.  in  length.  Life  after  birth  at  the  sixth 
month  may  be  carried  on  for  several  days,  and  jtossibly  for  longer,  if 
sufficient  care  be  taken  to  imitate  the  intrauterine  environment  in  thi- 
matters  of  temperature  and  protection  from  injury. 

Seve.vth  Month. 
The  seventh  month  (fifth  of  foetal  life)  lias  many  characters  in  common 
with  the  sixth.  In  it,  again,  there  is  rapid  growth  in  length  and  weight  : 
at  its  termination,  the  foetus  measures  38  cms.,  and  weighs  1170  grms.  or 
41  oz.  Lanugo  covers  the  whole  body  except  on  the  ]ialmar  and  plantar 
surfaces  of  the  hands  and  feet  respectively  ;  and  the  vernix  caseosa  is 
plentiful,  although  it  is  to  be  borne  in  mind  that  in  some  foetuses  the 
vernix  is  never  present  in  great  amount.  In  the  eye  the  portion  of  the 
tunica  vasculosa  which  lies  in  front  of  the  lens  (memhrana  ■pupiUaris)  is 
very  marked,  but  begins  to  atrophy  before  the  end  of  the  month.  If 
sections  be  made  of  the  skin  at  this  age,  elastic  fibres  will  be  seen  in  it,  and 
the  sweat  glands  will  be  found  with  the  excretory  ducts  extending  thniugh 
the  epidermis.  There  is  branching  of  the  glands  which  comiiose  the 
mainmse,  biit  these  do  not  yet  show  a  lumen. 


V- '  c  /■(  .^ 

LATER   MONTHS   OF   FCETAL  Llpfis^ 

Ossitie  nuclei  appear  in  the  seecmil  ami  third  pieces  nf  the  meso-stenunn, 
in  the  ethmoiilal  region  (although  the  ethmoid  itself  does  not  ossify  till 
after  birth),  and  in  the  astragalus.  In  the  brain  the  fissure  of  Sylvius  is 
deeper  and  narrower,  and  its  margins  are  ajjproaohing  each  other  to 
hide  from  view  the  island  of  Eeil ;  and  the  retro-central  fissure  of  the 
parietal  lobe  is  marked  off.  The  dentine  increases  in  amount  on  the  germs 
of  the  temporary  teeth,  it  is  to  be  recognised  in  the  first  molars ;  and  the 
(ither  permanent  teeth  have  the  enamel  organ  fully  differentiated.  In  the 
male  the  descent  of  the  testicle  is  continued,  for  it  is  now  drawn  into  the 
niimth  of  the  sac  of  the  tunica  vaginalis  behind  the  processus  vaginalis ; 
and  it  may,  before  the  end  of  the  month,  lie  in  the  scrotum.  Meconium  is 
fi  lund  in  most  of  the  large  intestine. 

The  placenta  weighs  from  210  to  250  grms.  (374  grms.,  Hecker),  and 
the  umbilical  cord  measures  42  cms.  in  length.  The  foetus,  if  born  alive 
at  this  month,  may  quite  well  survive  its  birth,  and  continue  to  live  if 
well  cared  for,  but  it  is  specially  susceptible  to  changes  of  temiaerature  and 
to  the  onslaughts  of  pathogenic  microbes. 

Eighth  Month. 

The  eighth  month  of  intrauterine  and  the  sixth  of  fwtal  life  (29  to  32 
weeks)  is  marked  by  comparatively  trifling  changes,  the  truly  epoch-making 
jieriods  of  antenatal  existence  having  now  all  passed.  The  length  of  the 
foetus  is  from  39  to  41  cms.,  and  the  weight  has  increased  to  1571  grms. 
or  3^  lbs.  There  is  more  hair  on  the  scalp  and  less  lanugo  on  the  body 
than  in  the  earlier  months,  much  of  the  lanugo  having  been  shed  into  the 
liquor  amnii.  The  nails  are  now  quite  horizontal  as  regards  the  underlying 
skin,  but  they  do  not  project  beyond  the  finger-tips.  The  testicles  of  the 
male  foetus  will  be  found  in  the  scrotum. 

The  placenta  weighs  about  451  grms.  (one-third  of  the  weight  of  the 
foetus,  circa)  and  the  umbilical  cord  measures  46  cms.  in  length.  Birth  at 
this  month  ought  not  to  be  followed  by  early  death,  although,  of  course, 
such  an  infant  is  less  likely  to  survive  than  nne  honi  at  the  full 
time. 

Ninth  JNIonth. 

The  ninth  month  is  comparatively  featureless  save  for  continued  rapid 
growth;  the  length  is  now  from  42  to  44  cms.  (15'25  to  16  inches)  and  the 
weight  1942  grms.  (4|-  and  later  5 J  lbs.).  There  is  a  marked  amount  of 
aiUpose  tissue  beneath  the  skin,  and  there  are  often  miliaria  about  the  tip 
of  the  nose.  The  vernix  caseosa  is  very  evident.  Towards  the  close  of 
this  month  the  ossific  nucleus  in  the  lower  epiphysis  of  the  femur  may 
occasionally  be  made  out  as  "  a  more  or  less  circular  blood-red  spot  in  the 
midst  of  milk-white  cartilage  " ;  but  more  commonly  it  is  not  visible  till 
the  middle  of  the  tenth  (lunar)  month.  The  placenta  weighs  about  461 
grms.  (one-fourth  of  the  weight  of  the  foetus),  and  the  umbilical  cord 
measures  47  cms.  in  length. 

Tenth  Month. 

The  tenth  (lunar)  month  of  intrauterine  life,  or  the  eighth  month  of 
truly  foetal  life,  culminates  in  the  attamment  of  the  maturity  or  ripeness  of 
the  foetus — further  developments  of  the  organism  will  take  place  m  its  extra- 
uterine environment,  but  the  end  of  profitable  intrauterine  life  has  been 


9:^      AXTENATAI.  I'ATHOLOOY  AND  HY(;IKN"F. 

reached.  In  tlic'su  lust  four  weeks  (thivty-.seveii  tn  f(irty)  tlicre  is  still 
great  activity  of  growtli,  and  by  tlie  end  iif  the  ninutli  a  weight  nf  7^  lbs. 
or  thereby  has  been  attained,  anil  a  length  nf  .51  cms.  (20  in.)  reached. 
The  skin  is  now  of  a  j)aler  pink  and  may  be  almost  white  ;  and  the  lanugo 
has  all,  or  nearly  all,  disajipeareil.  The  eyelids  are  quite  Kei)arate,  the  eye- 
brows anil  eyelashes  are  well  developed,  and  tlie  cartilages  of  the  nose  and 
ears  are  firm.  The  nasal  miliaria  are  scanty  as  (•onqiared  with  the  ninth 
month.  The  venii.x  caseo.sa  is  evident,  and  the  nails  project  beyond  tin- 
finger-tips.  Further,  the  infant  has  a  general  appearance  of  maturity, 
which  is  difficult  to  express  in  words,  but  which  is  known  to  the  expert  ; 
there  is  also  a  certain  immovability  of  the  cranial  bones  ;  and  the  umbilicus 
is  near  the  centre  of  the  Ixidy.  Ossification  shows  further  progress:  an 
ossific  nucleus  is  now  to  be  found  in  the  cuboid  ami  one  in  the  hyoid  bone, 
while  "  the  circular  blood-red  spot  in  the  midst  of  the  milk-white  cartilage  " 
of  the  lower  epiphysis  of  the  femur  is  now  recognisable,  and  measures  from 
two  to  three  lines  in  diameter.  There  is  an  indication  of  a  similar  but 
smaller  "blood-red  spot"  in  the  upper  end  of  the  tibia.  During  this 
month  accessory  cerebral  fissures  api)ear,  and  the  margins  of  tlie  fissure  of 
Sylvius  approximate  and  completely  hide  from  view  the  island  of  Eeil.  In 
the  convolutions  there  is  a  certain  amount  of  myelination,  as  well  as  in 
the  spinal  cord,  medulla,  pons,  corpora  cpiadrigemina,  and  optic  thalamus  ; 
and  the  myelination  is  situated  round  the  primary  fissures  (Sylvian, 
Eolandic,  calcarine)  and  in  areas  which  are  the  end-stations  of  the 
afferent  projection  systems  (F.  W.  ]\Iott,  Brit.  Med.  Journ.,  vol.  i.  for  1900, 
p.  1517).  The  meconium  is  found  in  the  rectum,  at  least  in  the  sigmoid 
flexure,  at  the  end  of  the  tenth  month  ;  and  there  is  often  some  urine  in 
the  bladder. 

The  environmental  changes  are  preparatory  to  the  separation  of  the 
fcetus  from  its  maternal  connections.  The  umbilical  cord  is  about  51  cms. 
in  length.  The  placenta  has  increased  but  little  in  weight — it  now  weighs 
about  481  grms. — and,  since  the  weight  of  the  foetus  is  about  3400  grms., 
it  follows  that  the  placenta  is  only  a  seventh,  instead  of  a  fourth,  of  the 
foetal  weight.  At  the  time  when  the  foetus  is  increasing  by  so  many 
pounds  a  month,  the  placenta  is  only  adiling  a  few  grammes.  It  is  evident 
that  the  time  of  placental  activity  is  nearly  over  ;  and  vascular  changes  in 
the  structure  of  that  organ  have  been  taking  place  during  the  tenth  month, 
which  facilitate  the  separation  of  parts  soon  to  occur.  The  full-time  infant, 
when  born  ali\'e,  soon  breathes  freely,  cries  loudly,  makes  active  move- 
ments of  the  limbs,  and  takes  the  breast. 


Summary. 

Such  are  the  changes  which  take  place  during  the  life  of  the 
fcetus  as  nieasureil  by  months.  Wonderful  clianges  they  are,  yielding 
in  wonderfulness  only  to  the  changes  of  the  embryonic  jieriod.  They 
are  worthy  of  careful  stud)'  by  the  student  of  Antenatal  Pathology; 
they  must,  in  very  trutli,  be  studied  by  him  with  assiduity  if  he  is  to 
make  any  progress  at  all  in  clearing  away  the  dust  antl  rubbish  which 
have  been  cast  all  o\-er  the  subject.  The  dust  and  rubbish  of  mis- 
taken views  of  firtal  growth  and  development  and  function  liave  in 
the  past  done  mucli  to  almost  crush  the  life  out  of  our  subject  and  to 
bury  it  deep.     Yet  a  subject  with  wonderful  vitality  !    For  it  has  not 


FCETAL   CiROWTH  93 

been  crushed  and  stifled,  no,  not  even  by  all  the  erroneous  notions 
and  theories  which  have  been  cast  upon  it  bj-  those  who  believe  in 
•'  maternal  impressions,"  and  would  explain  all  antenatal  phenomena 
by  them.  Let  us  therefore  take  heart  of  courage,  and  proceed — • 
more  slowly,  doubtless ;  more  really,  it  is  confidently  anticipated. 

The  changes  characteristic  of  or  occurring  in  fo'tal  life  may  be  all 
arranged  in  two  groups :  those  which  are  typically  ftetal  in  one,  and 
those  which  are  embryonic  or  reminiscent  of  the  embryonic  in 
another.  In  the  former  must  be  placed  the  growth  in  weight  and 
the  increase  in  length  of  the  foBtus  during  the  eight  lunar  months  of 
fa?tal  existence.  The  schemes  (Figs.  11  and  12)  are  of  service  in  giving 
a  graphic  and  diagrammatic  representation  of  these  two  outstanding 
phenomena  of  fcetal  life.  If  the  neofcetal  period  be  included,  the 
increase  in  weight  is  from  one-ninth  of  an  ounce  at  six  weeks  to  seven 
and  a  half  pounds  at  full  term,  while  that  in  length  is  from  IS  cms. 
at  six  weeks  to  51  cms.  at  the  full  tei-m.  The  increase  in  weight  will 
serve  best  for  forming  an  estimate  of  vital  activity,  for  there  is  a 
fallacy  in  the  calculation  of  the  length.  It  will  be  seen  that  the 
period  of  most  active  growth  in  weight  is  between  the  fourth  and 
fifth  months  (from  the  sixteenth  to  the  twentieth  week),  when  the 
weight  quadruples ;  during  the  next  month  it  nearly  trebles ;  during 
the  next  it  does  not  double ;  and  thereafter  its  monthly  gain  is  about 
a  half.  The  period  of  most  active  growth  in  weight  therefore  corre- 
sponds to  the  time  just  following  the  full  establishment  of  the  placental 
economy.  If,  now,  the  weight  of  the  placenta  at  the  various  mouths 
of  fcetal  life  be  inquired  into,  it  will  be  found  that  its  period  of  most 
active  increase  in  weight  coincides  with  that  of  the  fostus ;  in  other 
words,  is  the  fourth  month,  the  sixteenth  to  the  twentieth  week.  In 
the  scheme  of  placental  growth  in  weight  (Fig.  13)  this  is  brought 
out.  The  placenta  more  than  quadruples  its  weight  between  the 
fourth  and  fifth  months  ;  in  the  next  month,  it  does  not  even  double, 
only  aliout  a  half  being  added  ;  in  the  next,  less  than  a  half  is  added  ; 
in  tlie  next,  about  a  sixth  is  the  increment ;  in  the  next,  less  than  a 
fifteenth ;  and  in  the  last  month,  less  than  a  sixteenth.  Both  the 
fcetus  and  the  placenta  have  their  maximum  rate  of  growth  at  the 
same  time  in  intrauterine  life ;  but  the  latter  much  sooner  shows 
signs  of  lessening  growth-rate,  having  a  much  shorter  life-history,  so 
to  say,  and  is  akeady  ready  to  perish  when  expulsion  from  the  uterus 
occurs. 

The  second  group  of  changes,  those  which  are  reminiscent  of 
embryonic  life,  contains  phenomena  of  development  in  contradistinc- 
tion to  the  alterations  in  size  and  weight  which  characterise  the 
purely  foetal  changes.  The  embryonic  changes  are  much  more 
marked  in  the  early  than  in  the  later  months ;  in  fact,  in  the  ninth 
and  tenth  months  they  have  to  be  closely  looked  for,  being  then 
almost  insignificant.  Further,  even  in  the  early  months  they  do  not 
aftect  equally  all  the  organs  or  all  the  regions  of  the  body.  Speaking 
broadly,  the  central  part  of  the  body  and  the  viscera  of  the  thorax 
and  upper  part  of  the  abdomen  therein  contained  show  little  or  no 
changes  of  any  importance,  while  the  cephalic  and  caudal  ends  with 


Ltn^tli  ill  cms.  'A 
Months  .  .  10 
Weeks     .  40 


FCETAL   GROWTH 


95 


D 


n 

96 


ANI'KNATAl.    I'A  11 1(  )I.()(  l^' 


□  i- 


ORDER   OF   DE\ELOFMFAT   OF   ORCJANS 


97 


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o 

V! 

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S&3 


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o 

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98  ANrKNATAI.    I'ATHOI.OCiY   AND    IIVCIENK 

their  viscera,  the  skeleton,  the  skin,  and  tlie  linilis,  exliibit  certain 
evident  alterations  of  a  tlevelopniental  kind.  There  are,  for  instance, 
few  changes  to  be  recorded  in  connection  with  the  heart,  lungs,  liver, 
stomach,  intestine,  pancreas,  spleen,  kidneys,  and  thymus ;  on  the 
other  hand,  there  are  alterations,  both  many. and  important,  to  be 
noted  in  the  skeleton,  lirain,  face,  ears,  eyes,  teeth,  genitals  (male  and 
female),  spinal  cord,  blood,  joints,  skin,  and  skin  ajipendages.  To 
revert  to  a  comparison  I  have  already  instituted  when  writing  of  the 
emljrj'o — the  fietus  may  be  compared  to  a  city,  the  centre  of  which 
with  its  main  avenues  of  traftic  and  its  chief  buildings  is  almost 
complete,  while  its  suburbs  are  scarcely  yet  fully  marked  out,  far  less 
definitely  constructed.  Tn  the  foHus  the  thoraco-abdominal  cavity 
and  contents  constitute  the  centre  of  the  city, and  the  lirain, genitals, 
many  of  the  bones,  skin,  etc.,  are  the  rudimentary  but  fast-extending 
and  developing  suburbs.  Some  idea  of  this  conception  may  be 
obtained  from  the  accompanying  scheme  (Fig.  14). 

In  this  chapter  have  been  considered  the  changes  which  occur  in 
the  organism  and  convert  it  from  an  emlnyo  into  a  "  new-ljorn  " 
foetus,  and  again  from  a  "  new-born "  into  a  full-time  or  mature 
fcetus,  ready  for  and  capalile  of  surviving  its  transference  into  the 
world  outside  the  maternal  womb.  There  are  many  parts  of  this 
complicated  series  of  changes  about  which  we  are  in  darkness.  Our 
knowledge  of  it  is  similar  to  that  which  we  at  night  olitain  of  a  land- 
scape over  which  an  occasional  flash  of  sheet-lightning  ])lays  fitfully, 
illuminating  it  for  a  moment  and  then  leaving  the  ilarkness  almost 
more  intense.  For  no  one  has  ever  been  able  to  watch  month  by 
month  and  day  by  day  the  fwtus  growing  and  developing  in  the 
womb ;  and  our  knowledge  of  its  growth  and  development  has  been 
made  up  from  glimpses  of  it — sheet-lightning  flashes — obtained 
through  its  more  or  less  accidental  expulsion  prematurely  from  the 
uterus.  Glimpses  of  its  life  truly  they  are,  for  death  ipiickly  follows 
any  such  early  expulsion  from  the  natural  en\ironment.  Even 
regarding  the  last  two  or  three  months  our  information  is  scanty, 
and  in  some  measure  incomplete ;  but  such  as  it  is  we  now  set  it 
forth — in  the  following  chapters. 


CHAPTER   YIII 

Anatomy  of  the  Mature  Fietus.  Anatomy  of  the  region  of  the  Head,  Spine, 
Neck,  Thorax,  Alidomen,  Pelvis,  and  Limbs.  Anatomy  of  the  Umbilical 
ford,  Placenta,  and  Membranes. 

Ix  this  chapter  and  in  the  two  that  follow  an  attempt  is  made  to  state 
what  is  known  regarding  the  anatomy  and  physiology  of  the  f  idl-time 
or  nearly  full-time  foetus.  To  be  more  exact,  the  attempt  is  made  to 
state  wherein  the  anatomy  and  physiology  of  the  foetus  ditler  from 
the  anatomy  and  pliysiology  of  the  child  and  adult.  With  regard  to 
foetal  anatomy  we  are  on  fairly  sure  ground,  for  it  is,  alas !  a  too 
common  circumstance  that  a  foetus  comes  into  the  world  dead  and  of 
use  only  for  dissection :  by  such  dissections  and  sections  a  knowledge 
of  the  structural  peculiarities  of  the  unborn  infant  has  been  built 
up.  By  a  sad  hap  it  sometimes  comes  about  that  a  mother  dies  with 
her  infant  undelivered  in  her  woml  i ;  from  the  examination  of  such 
cases  certain  details  of  foetal  anatomy  have  been  more  accurately 
ascertained.  With  fa?tal  physiology  there  is  no  such  certainty  of 
information ;  there  is  much  speculation  and  there  are  many  theories, 
and  the  investigator  has  not  always  "  avoided  the  guesser's  darkening 
of  knowledge."  The  defects  in  our  acquaintance  with  the  peculiar- 
ities of  fcetal  physiology  are  responsible  for  our  ignorance  of  many  of 
the  phenomena  of  fcetal  pathology ;  as  a  matter  of  fact,  we  have  had 
to  deduce  several  of  our  conclusions  regarding  the  physiology  of 
intra-uterine  life  from  the  studv'  of  the  disturbances  of  fu^tal  function, 
i.e.  from  the  diseases  of  the  foetus.  There  is  accordingly  much  un- 
certainty and  an  appallmg  paucity  of  facts — facts,  therefore,  in  this 
subject  are  of  more  than  usual  value.     May  their  number  increase  ! 

Anatomy  of  the  Fcetus. 

Within  recent  years  our  knowledge  of  the  anatomy  of  the  full- 
time  fiptus  has  been  added  to  and  conlirmed  liy  the  sectional  method 
of  study.  In  1891  I  published  the  results  of  the  investigation  of  a 
number  of  foettises  by  means  of  frozen  sections  (1,  37,  38,  39,42,47) ; 
and  since  then  have  appeared  the  works  of  H.  Mettenheimer  (in 
Schwalbe's  Morphol.  Arheiten,  Bd.  iii.,  Hft.  2,  1893),  of  F.  Merkel 
{Mcnschliche  Embryonm,  Gottingen,  1894),  and  of  J.  H.  Chievitz 
{Topo[irttphical  Anatomy  of  Full-term  Human  Fcetus,  Copenhagen, 
1899).  Merkel  has  endeavoured  to  extend  the  investigation  to 
foetuses  of  different  ages  from  three  months  onwards,  and  0.  Scbiifler 


100 


ANTKXATAL    I'ATHOLOCiY    AND    HYCIKNK 


(ill  F.  von  Wiiiki'l's  Beric/ttr  tnid  Studicn  in  Miuirhni.  pp.  13G-205, 
478-G54,  Leii)zi<:',  1892)  lias  made  many  accurate  measviremeiits ;  but 
tlie  number  of  sjiecimens  j-et  dealt  witb  is  ton  small  to  permit  of  the 
safe  formation  of  general  conclusions  with  regard  to  any  l)Ut  full-time 
fcrtuses.  I  do  not  pretend  here  U>  discuss  all  the  anatnmical  char- 
acters of  even  the  full-time  fu'tus  (for  sudi  fiUl  discussion  the 
reader  is  referred  to  my  work,  An  Introdndiun  to  the  Biscasr;  of 
Infancy,  or  to  the  other  books  above  mentioned),  but  will  deal  only 
with  the  more  prominent  peculiarities.  The  details  will  be  taken  up 
according  to  the  regional  method  of  anatomical  studv. 


The   Head  of  the  Foetus. 

The  head  of  the  foetus  is  relatively  large,  if  we  regard  the  adult 
proportion  as  the  normal :  and  the  younger  the  fo'tus  the  greater 

is  the  relative  largeness. 
Of  the  two  parts  of  the 
head — cranium  and  face 
— the  former  is  relat- 
ively larger  than  the 
latter.  The  cranium, 
which  is  composed  (if 
eight  bones,  is  divideil 
into  two  parts,  vault  and 
base :  the  cranial  arch 
(distance  from  the  root 
(if  the  nose  round  to  the 
liack  of  the  foramen 
magnum)  in  the  fu'tiis 
is  to  the  cranial  base 
approximately  as  o  to  1 ; 
this  is  the  highest  pro- 
Fic:.  i:,.  portionate  length  which 

it  attains,  and  in  the 
adult  it  is  as  2"7  or  2-8  td  1.  Tiie  bones  which  make  up  the  vaidt 
of  the  fa^tal  cranium  are  loosely  j(  lined  together  by  membrane  at  the 
sutures  and  fontanelles ;  every  student  of  Obstetrics  knows  the  sutures 
and  fontanelles,  for  they  are  the  parts  which  are  to  be  felt  during 
the  progress  of  labour.  It  is  presumed  that  the  reader,  too,  is  well 
acquainted  with  them.  The  base  of  the  cranium  is  made  up  of  the 
basiocciput,  the  sphenoid,  the  ethmoid,  and  the  petrous-temporals : 
these  bones,  unlike  tho.se  of  the  vault,  do  not  change  their  relati\-e 
position  as  the  result  of  pressure  brought  to  bear  uiion  them ;  there 
is  no  moulding  nf  the  basis  eranii  during  labour,  and  it  is  fortunate 
for  the  fcctus  that  there  is  not. 

The  form  and  diameters  of  the  head  of  the  full-time  foetus  (Fig.  15) 
are  not  those  of  the  new-b(U-n  infant  (Fig.  IG).  Only  a  few  hours 
may  sejiarate  the  fcctal  from  the  neonatal  state,  but  in  those  few 
hours  happens  liirtli,  and  in  liirth  the  unmoulded  head  of  the  fietus 
becomes  the  moulded  head  of  tlie  new-born  infant.     The  form  (if  the 


REGION    OF  THI".   HKAD 


101 


uiiiiioul<leil  or  normal  head  is  expressed  by  the  relative  lengths  of 
its  antero-posterior  and  lateral  diameters.  For  a  full-time  fa'tus, 
measuring  from  48  to  51  cms.  (19  to  20  inches)  in  length  the 
diameters  will  be  approximately  as  follow :  Maximum  antero- 
posterior, 13  cms.:  occipito-mental,  12-5  cms.;  occipito-frontal, 
11-5  cms.;  sub-occipito-bregmatic,  10"3  cms.;  bi-parietal,  10  cms.; 
and  bi-temporal,  8'7  cms.  During  labour  the  maximum  diameter 
greatly  increases  and  most  of  the  others  diminish,  the  form  of  the 
head  becoming  obliqiiely  sugar-loaf-shaped  from  before  baclcwards 
and  upwards.  The  ilistortion  of  labour  usually  passes  ott'  about  a 
week  afterwards,  but  it  may  be  to  a  greater  or  less  extent  permanent. 
In  the  meantime,  let  it  lie  borne  in  mind  that  the  form  of  the  fretal 
head  is  not  the  same  as  that  of  the  infant  during  and  just  after  liirth. 
It  is  not  yet  known  with  certainty  whether  the  fiotal  head  shows  a 
primitive  asymmetry ;  the  head  of  the  new-1iorn  infant  often  is  dis- 
tinctly asymmet- 
rical, but,  mani- 
festly, unilateral 
depressions  may 
he  due  to  the 
birth-traumatism 
which  has  just 
taken  place. 

The  brain,  like 
the  c  r  a  n  i  u  m 
which  contains 
it,  is  relatively 
large  in  the  ma- 
ture foetus — ■'  big 
but  inactive  "  is 
the  description 
which  has  some-  yia   le 

times  been  given 

of  it ;  big  it  certainly  is.  The  relatiiin  of  the  lirain  landmarks  to 
the  cranial  landmarks  is  in  some  details  different  from  what  it 
is  in  the  adult ;  but  the  facts  are  difficult  to  get,  fV>r  the  topography 
of  the  brain  of  the  unborn  fretus  is  practically  unknown,  and  it  is 
manifestly  fallacious  to  draw  conclusions  from  the  moulded  head 
after  birth.  The  following  statements,  therefore,  may  require 
revision.  The  Sylvian  fissure  is  at  a  higher  level  in  the  fcetus, 
and  lies  above  the  squamous  suture  instead  of  coinciding  with  it  as 
in  the  adult :  it  has  been  stated  that  the  lower  end  of  the  fissure 
of  liolando  lies  in  front  of  the  coronal  suture  in  the  fa^tus,  but 
my  observations  do  not  support  this  opinion,  although  they  show 
that  the  fissure  is  apparently  less  vertical  than  in  later  life ;  the 
parieto-occipital  fissure  corresponds  with  some  accuracy  with  the 
tip  of  the  occipital  bone  at  the  posterior  fontanelle,  and  lies  behind 
rather  than  in  front  of  tlie  laml)doidal  suture:  and  the  calcarine 
fissure  is  situated  approximately  opposite  the  occipital  protuberance. 
It  has  Ijeen  said  that  the  cerebrum  overlaps  the  cerebellum  to  a  less 


102 


ANTKN.Vr.M,    l'ArH()I.<)(i'>'    AND    lIVdIKNK 


extent  in  the  fuHus,  Imt  my  sections  do  not  sliuw  tliis  iieculiaiity 
(Figs.  17  and  18). 

' .:    rr  Thr-    ceiebral 

convolutions  arc 
les.s  complex  in 
tiie  fu'lus  than  in 
the  adult,  and  the 
sulci  arc  less  deep. 
It  may  he  that 
siimc  accessiiry 
fissures  are  not 
developed  till 
after  hirth,  and 
are  therefore 
postnatal  forma- 
'  tions,  but  about 
this  matter  there 
is  little  know- 
ledge. The  study 
of  the  miinitc 
anatomy  of  the 
foetal  brain  has 
recently  received 
a  great  impulse 
by  the  discovery 
of  Flechsig  that 
there  is  a  currcla- 
tion  between  the 
functions  of  sys- 
tems of  neuriines 
and  the  myelina- 
tion  "f  their 
axons:  in  the  full- 
time  fcEtus,  the 
whole  aflerciii 
tract  conveyin- 
tactile,  articular, 
muscular,  aiul 
visceral  sensa- 
tions by  the  ]ios- 
terior  columns. 
Fig.  17.— Mesial  sagittal  section  of  fii'tii.s.  In  the  upper  part  of  ^ii  j.  tleilniiiis 
the  region  of  the  head  the  section  has  passed  slightly  to  the  '""-'••  ^H'l''""'  •  . 
right  of  the  middle  line,  leaving  the  fal.x  cerebri  unexposed,  and  coroua  radl- 
rt,  Anterior  fontanelle  ;  b,  presphenoid  ;  c,  thyroid  cartilage  ;it;;i  is  mvcliuatcd  ; 
oflavyuxirf,   tongue  :  «,  left  innominate  vein  ;  /",   thymus  i    -^    V,-,ll.->«t;    if 

1       1  1.  •  ■  1  ■         •     ii      1        ».      1     *i       !;...,«  .    ;      anil    IL    I<.)ll()\Ns,    H 

gland;  g,  tricuspid  opening  in  the  heart ;  n,   the  liver;  '•      ,       ,  ,,       •        f 

the  pylorus  ;  k,  transverse  colon  ;  I,  the  ]iancrea.s  ;  m,  lobus  the  llVpotlieSlS  01 
spigeiii  of  liver  ;  n,  first  lunihar  vertebra  ;  o,  left  auricle  ;  Flechsig  be  COV- 
;<    aorta;  r,   trachea  ;  s,  .seventh  cervical  vertebra  ;  t,  the  j.   ^^^.^^  jnipres- 

iiharynx  ;  r,  cerebelluni  ;  i''.   posteiior  lontaiicUe.  .      '  ,  '    . 

sions  have,  during 
the  last  three  or  four  months  of  intrauterine  life,  been  ]iassing  along 


REGION    OF  THE   FAC 


these  bundles  of  fibres  to  the  receptive  centres  in  the  cortex,  Eolandic 
area.     From  these  observations  niucli  light  may  be  expected  to  be 

thrown       upon       the 

physiology  of  the  foetal 
brain  (vide  W.  W. 
Ireland's  Digest  of 
])apers  by  Flechsig, 
Dullken,  and  Nissl,  in 
Journ.  Mcnt.  Sc,  Janu- 
ary 1899). 

The  small  size  of 
the  face  of  the  foetus 
as  compared  with  the 
cranium  is  partly  due 
to  the  small  size  of  the 
superior  maxilla  ;  the 
antrum  of  Highmore 
and  the  alveolar  pro- 
cess of  the  upper  jaw 
are  both  ill-developed. 
The  inferior  maxilla 
also  is  small  in  the 
foetus;  its  symphysis 
is  not  fully  ossified ; 
and  its  angle  is  obtuse. 
In  a  well-nourished 
full-time  infant  the 
cheeks  are  pi'ominent, 
and  this  prominence 
is  partly  caused  b}'  the 
presence  of  a  special 
encapsulated  mass  of 
adipose  tissue  (Fig. 
19) ;  this  mass  of  fat 
lies  upon  the  bucci- 
nator and  partly  upon 
the  masseter  muscle, 
and  has  the  risorius 
.superficial  to  it ;  it  is 
called  the  sucking-pad 
("  Saugpolster  ").  Two 
anatomical  peculiar- 
ities of  the  Ijuccal 
cavity  in  the  foetus 
are  revealed  by  frozen 
sections :  the  gums  are 
not  in  contact  even 
when     the    jaws    are 


Fig.  18. — Left  lateral  vertical  section  of  foetus.  Eight 
face  of  section  seen,  a,  anterior  i'ontanelle  ;  6,  jios- 
terior  fontanelle  ;  c,  eerelielluni ;  d,  tliynnis  gland  ; 
c,  left  lung,  upper  and  lower  lobes  ;  /,  spleen  ;  cj,  left 
supra-renal  capsule ;  h,  left  kidney ;  i,  left  psoas 
muscle  ;  j,  twelfth  rib  ;  k,  umbilical  cord  ;  I,  trans- 
verse colon  ;  m,  liver,  left  lobe ;  n,  stomach  ;  o,  left 
ventricle  of  heart  ;  ji,  right  ventricle  of  heart  ;  r, 
left  sucking-pad  ;  s,  left  malar  bone  ;  t,  left  eye. 


tightly  closed,  and  the  lower  jaw  lies  in  a  plane  posterior  to  that  of 
the  upper  jaw.     The  nasal  cavities  are  relatively  small;  the  orbits 


104 


ANTIAAIAI.    I'AIIIOI.OCY    AM)    H^dlKNT. 


and  their  Cdiiteiits  do  not  dilltT  in  tliuir  anatomy  frmn  these  parts  in 
the  child  (ir  aihilt. 

The  ear  of  the  full-time  fcetus  has  certain  characters  in  which  it 
resembles  the  ear  of  the  adidt,  and  others  in  which  it  differs  from  it. 
The  internal  ear,  for  instance,  is  very  completely  developed,  and  s(j 
are  the  tympanic  cavity  and  ossicles  and  the  mastoid  antrum.  It  is  Xi< 
be  borne  in  nund,  however,  that  in  the  ri>oi  of  the  tympanic  cavity 
there  is  an    unclosed    siit\n-e,    the    petro-.s(|uamous  (Fi^'.   20).     The 

ivity  is  said  tn 
I'  tilled  with  a 
gelatinous  sub- 
stance,  e  m  - 
l>ryonic  connect- 
ive tissue  whicli 
has  undergone  re- 
gressive change ; 
air  enters  after 
liirtii.  The  re- 
maining parts  of 
tl]e  ear,  on  the 
other  hand,  arc 
far  from  coni- 
te  develiip- 
nient.  The  Eus- 
tachian tube  is 
short,  runs  al- 
most horizontal, 
and  cau  hardly 
be  said  t<.i  possess 
an  osseous  part. 
The  external 
auditory  meatus 
is  osseous  in  its 
inner  third  alone 
and  tliat  onlv  in 

.  J». — Loi'onai  .secuon  or  neaa  oi  muis  in  ]iiaiie  iiosienor  in  .  c  fi      ij 

tlie  eyeballs  (viewed  from  behind),  |  natnral  size,    a,  Frontal  t'le  root,  the  tloov 

suture;  b,  longitudinal  sinus;   c,  longitudinal  fissure  with  being     made     U]i 

I'alx  cerebri ;  d,  beginning  of  sylvian  Kssure  :  c,  left  optic  ]),.     jjjg      tibrOUS 

nerve;/,   left  sufking-pad  ;  y,  cystic  tumour  below  tongue  ;  "_  .  1.  t  . 

h,   tongue  out  transversely  :   h,  right  ua.sal  fossa,  showing  tympanic    platl^  , 

superior,  middle,  and  inferior  meatuses  ;  I,  orbital  jilate  of  the    mastoid    air 

frontal  bone  ;  ///.,  zygoma  near  its  root ;  ji,  tooth  germ  in  cgUs  are   not  de- 
ui)i)er  maxilla.  ,         ,  ,\, 

"  veloped;  and  the 

annulus  tympanicus  forms  a  very  slight  projection.  The  meatus  with 
the  soft  pirts  in  situ  is  proliably  of  about  the  same  relative  length  as 
in  the  child  or  adult;  it  has  no  anterior  or  posterior  curve  ujion  it  : 
and  its  inner  or  tym])anic  end  is  somewhat  enlarged  to  form  the 
sinus.  The  external  ear,  then,  is  in  a  transition  state  in  the  fa't\is  ; 
so  is  the  skull  in  its  neighbourhood.  Anterior  to  the  meatus  is  tlie 
antero-lateral  fontanelle  (region  "  pterion"),  while  jiosterior  to  it  is 
the  postero-lateral  fontanelle  (region  "  astei'ion  "),  and  between  these 


Fig.  19. — Coronal  section  of  head  of  futus  in  jilane  posterior  to 


THE   EAR   OF  THl'.   IXKTUS 


105 


two  foiitanelles  is  a  medley  of  small  bones  ami  cartilage  islands, 
.showing  that  development  is  not  far  advanced  in  this  neighbourhood. 
Buntaro  Adachi  (Zfschr.  f.  Morjiliol.  u.  Anthrop.,  ii.  p.  223,  1900)  has 
given  an  interesting  description  of  the  changes  which  occur  in  this 
neighbourhood  in  the  fcetus  and  new-born  infant.  Post-natal  develop- 
ment is  necessary  before  the  tympanic  and  snuamoso-zygomatic  parts 


Fig.  20. — Coronal  section  of  head  of  fietus  in  plane  of  the  middle  ear,  viewed 
from  behind,  right  side  slightly  jiosterior  to  left,  ;}  natural  size,  a. 
External  auditory  meatus  (left) ;  /<,  membrana  tympani ;  r,  lobule  of  left 
ear ;  d,  helix  of  ear ;  c,  odontoid  jirocess  of  axis  vertebra  ;  /,  basi- 
s{)henoid  ;  g,  incus,  with  stapes  in  fenestra  ovalis  ;  h,  petro-squamous 
sutiu'e  in  roof  of  tympanic  cavity :  j,  sylvian  fissure  ;  k,  squamous 
suture  ;  I,  sagittal  sutui'e  ;  m,  superior  longitudinal  sinus  ;  n,  lateral 
A'entricle  ;  o,  third  cerebral  ventricle. 

of  the  temporal  bone  are  fully  formed.     The  pharyngeal  tonsil  is  said 
to  be  poorly  developed  in  the  fa;tus. 

In  frozen  sections  of  the  head  the  hypoiihysis  cerebri  can  be  seen 
in  the  middle  line  lying  in  the  sella  turcica  (Fig.  17).  Below  it,  in 
the  sphenoid,  can  sometimes  be  seen  traces  of  the  early  canalis 
cranio-pharyngeus ;  I  have  seen  these  traces  in  one  case,  a  dropsical 
fcetus. 


lOG  ANTKNATAI.    l'AllI()I.()(iV    AM)    HVCIIKNE 

The   Region  of  the  Spine. 

The  spine  nf  the  I'li'tiis  is  "a  Wdiuler  (if  li<;htuess  aud  flexibility," 
for  its  ossiticatiiiii  is  incomplete  (is  not  indeed  complete  till  far  on  in 
postnatal  life)  and  there  is  much  cartilaffe  in  it.  Any  one  who  has 
handled  a  ne\v-l)orn  infant  must  have  been  struck  by  the  flexibility 
of  the  s|)ine  and  the  facile  manner  in  whicli  the  head  swun^'  forwards 
and  backwards  and  to  the  side ;  the  movements  of  the  head  are  due 
to  the  flexibility  of  the  cervical  part  of  the  vertebral  column  rather 
than  to  great  range  of  movement  at  the  occipito-atlantoid  articula- 
tions;  indeed,  tlie  condyles  of  the  occiput  are  nearly  flat,  and  .so  are 
the  articular  surfaces  on  the  lateral  masses  of  the  atlas,  cliaracters 
whicli  little  fit  them  for  extensive  mcnement. 

In  the  fwtus  in  utero,  lying  as  it  does  with  a  greater  or  less 
degree  of  flexion  of  its  trunk  and  of  its  head  upon  its  trunk,  the 
spine  shows  a  general  anterior  concavity.  The  single  arch,  with 
concavity  forwards,  is  slightly  broken,  however,  liy  the  yiromontory 
of  the  sacrum,  which  produces  two  unequal  secondary  curves  witli 
anterior  concavity.  Other  curves  have  been  desci'ilied  as  present  at 
birth,  but  the  truth  is  that  any  curves  may  be  given  to  the  s)iine  liy 
altering  the  po.sition  of  the  ftetus ;  none  of  them  are  flxed.  Further, 
by  extension  of  the  head,  the  cohunn  may  be  made  almost  straight. 
There  is  a  slight  lateral  deviation  in  the  dorsal  region. 

Inspection  of  the  liack  of  the  fojtus  reveals  the  vertelu-al  spines  as 
a  row  of  ])i'ojectious  on  a  rounded  surface,  tor  the  median  depression 
does  not  appear  till  later,  when  it  is  caused  by  develojiment  of  the 
spinal  muscles.  The  spine  of  the  seventh  cervical  vertebra  is  not 
specially  prominent ;  it  certainly  does  not  yet  deserve  the  name 
"  prominens."  On  account  of  the  forward  flexion  of  the  head  upon 
the  trunk  of  the  fcetus  in  utero,  the  back  part  of  the  head  aud  the 
back  of  the  trunk  tVirm  a  continuous  curve  with  Init  slight  indication 
of  a  neck  grom-e. 

In  the  adult  the  length  of  the  cervical  region  of  tlie  sjiine  is  to 
that  of  the  hnnbar  as  '1  to  3;  in  the  foBtus  it  has  been  stated  by  snmo 
that  the  cervical  is  e(|ual  to  the  hunbar  part  of  the  verteliral  cuhinin  : 
it  is,  however,  more  exact  to  say  that  before  birth  the  lumbar  region 
is  only  slightly  longer  than  the  cervical.  My  measurements  give 
18  per  cent,  of  the  length  of  the  spine  for  the  cervical  region,  40  jier 
cent,  for  the  dorsal,  22'5  per  cent,  for  the  lumliar,  aud  about  19  jier 
cent,  for  the  sacro-coccygeal.  The  relation  of  the  spinal  cord  to  the 
spinal  column  varies  at  ditt'erent  jieriods  in  intrauterine  life :  at  the 
tliird  and  fourth  months  the  cord  and  the  colunni  are  of  practically 
equal  length,  the  conus  terminalis  ending  opposite  the  second 
coccygeal  vertelira;  at  the  full  term,  however,  it  ends  opposite  tlie 
first  or  second  lumliar;  at  the  fifth  month  it  is  opposite  the  fourtli 
lumbar  (Chievitz,  op.  cit.,  p.  20). 

In  the  full-time  fcetus  there  are,  as  a  ndc,  tlnee  laimary  centres 
of  ossification  in  each  vertebra — one  central  for  the  Ixidy,  and  two 
lateral  for  the  arches  and  jirocesses ;  but  certain  vertelira-  oiler 
exceptions.     The  atlas  has  its  anterior  arch  cartilaginous ;  but  then 


REGION    OF   THK    NFXK  107 

its  real  body  is  doubtless  the  oddiitoid  iirncess  of  tliu  axis,  and  in  it 
one,  sometimes  two  ossific  centimes  are  found.  The  tive  parts  of  tlie 
saerum  usually  follow  the  general  jilan,  and  exhibit  one  central  and 
two  lateral  primary  centres  in  each;  liut  the  coccyx  is  commonly 
quite  cartilaginous,  altliough  a  single  ossific  nucleus  may  be  occasion- 
ally noted  its  first  part  (Lambertz,  Die  Entwicliunfi  des  menschlichen 
Knochcngerustcs  wdhrcnd  des  fdtidcn  Lehrns  dargestellt  an  Rijntyen- 
lildern,  p.  18,  Hamburg,  1900). 

The  Region  of  the   Neck. 

The  ueck  of  the  full-time  foetus  is  noteworthy  for  its  apparent 
shortness.  This  character  is  due  in  part  to  the  high  position  of  the 
sternum,  in  part  to  the  alnindance  of  suljcutaneous  fat  in  the  region, 
and  in  part  to  the  relatively  large  size  of  the  head.  As  has  been 
noted,  the  cervical  part  of  the  spine  is  not  relatively  short,  but 
relatively  long  in  the  foetus.  In  connection  with  this  region,  I  may 
refer  to  the  hyoid  bone,  the  larynx,  the  trachea,  the  pharynx,  and 
the  thyroid  gland.  All  these  structures  lie  at  a  higher  level  in  the 
ueck  than  in  the  adult. 

On  account  of  the  tiexed  attitude  assumed  by  the  foetus  in  utero, 
a  vertical  line  drawn  through  the  hyoid  Isone  falls  in  front  of  the 
manubrium  sterni.  The  hyoid  lies  almost  in  contact  with  the 
thyroid  cartilage,  and  opposite  the  lower  part  of  the  body  of  the  third 
cervical  vertebra ;  but  with  tlie  head  extended  there  is  a  distinct 
thyro-hyoid  interspace,  and  the  hyoid  then  lies  on  the  level  of  the 
body  of  the  axis  vertebra.  The  ossification  of  the  basi-hyal  and 
of  the  great  wings  has  begun  in  the  full-time  foetus. 

The  larynx,  like  the  hyoid,  lies  at  a  higher  level  in  the  ueck  in 
the  fcetus  than  it  does  in  the  child  and  adult.  With  the  head 
sharply  flexed  (intra-uterine  attitude),  the  epiglottis  lies  opposite  to 
the  cartilage  between  the  liody  and  odontoid  process  of  the  axis 
vertebra,  and  the  lower  border  of  the  cricoid  is  in  the  plane  of  the 
disc  between  the  fifth  and  sixth  cervical  vertebne.  With  the  head 
erect  the  larynx  is  about  a  vertebra  higher.  The  length  of  the 
larynx  is  approximately  one-half  the  length  of  the  cervical  region  of 
the  spine.  A  finger's  breadth  (a  fcetal  finger's  breadth)  below  the 
hjwer  border  of  the  cricoid  is  the  isthnnis  of  the  thyroid  gland ;  the 
thyro-hyoid  and  crico-thyroid  membranes,  also,  have  each  the  breadth 
of  a  foetal  finger.  The  trachea  extends  from  the  level  of  the  body  of 
the  fifth  cer\'ical  vertebra  to  that  of  the  third  dorsal,  where  it 
bifurcates ;  its  level  is  a  little  higher  when  the  head  is  sharply  flexed  ; 
in  the  adult  the  l)ifurcation  is  one  vertebra  lower,  i.e.  opposite  the 
body  of  the  fourth  dorsal.  Part  of  the  trachea  is  in  the  neck  and 
part  in  the  chest.     Its  length  is  about  3  cms.,  and  its  diameter  from 

2  to  3  nims. ;  in  a  seven  months'  ftetus  it  may  lie  only  1  mm.  in 
diameter.  Its  truly  fmtal  fnrm  shows  au  antero-posterior  flattening, 
so  that,  while  the  antero-posterior  diameter  may  be  not  more  thau 

3  mms.,  the  transverse  may  lie  5  mms.  (Mettenheimer,  he.  eit.,  p.  310). 
The  pharynx  has  a  vertical  extent  of  about  4  cms. ;  the  naso-pharynx 


108  ANTKNATAI.    I'ATHOI.OdV    AND    HY(iIKNE 

is  a  very  small  s])ace.  It  ln'cmnes  coiitiuiioiis  with  the  ti}so])haL,'iis 
at  tlie  level  of  the  fifth  or  sixth  cervical  vertelira  ]iosteriorly,  ami  of 
the  cricoid  cartilafie  aiiterinrly. 

The  isthiiuis  of  the  thyroid  gland  lies  in  front  of  the  trachea 
(upper  four  or  five  rings)  opposite  tlie  liody  of  the  fifth  or  sixth 
cervical  vertelira  (Fig.  17);  with  tlie  head  flexed  it  is  in  contact  with 
the  iqijier  border  of  the  thymus  :  its  lateral  lobes  usually  extend  from 
the  lower  border  of  the  thyroid  cartilage  to  the  level  <if  the  fourth  or 
fifth  tracheal  ring;  the  weight  of  the  gland  is  about  7  grannnes. 

The  high  level  of  the  cervical  structures  in  the  full-time  foetus  is 
an  interesting  anatomical  fact,  reminding  us,  as  it  does,  of  the 
emliryonic  origin  of  these  parts  from  the  visceral  arches.  The 
gradual  descent  of  the  organs  in  the  neck,  which  takes  place  after 
birth,  is  in  jiart  due  to  the  straightening  of  the  body  and  head  which 
then  occurs,  but  in  greater  jiart  it  is  caused  by  the  downward  growth 
of  the  tongue  and  lower  jaw. 


The   Region  of  the  Thorax. 

The  thorax  of  the  full-time  tVetus  (Plates  II.  and  III.)  difl'ers  in 
certain  anatomical  details  from  that  regi(jn  of  the  body  in  the  adult 
or  child ;  it  differs  even  fi-om  the  thorax  of  the  uew-born  infant, 
although  the  foetus  may  be  separated  in  age  from  the  new-born  infant 
by  only  some  minutes — important  minutes,  however,  for  in  them 
respiration  has  or  may  have  begun.  It  will  be  convenient  to  con- 
sider, first,  the  thoracic  framework,  and,  second,  the  thoracic  contents. 

The  thorax  as  a  whole  is  situated  at  a  higher  level  qua  the  spine 
in  the  foetus  (Fig.  17) :  its  upper  limit,  tlie  iijiper  liorder  of  the 
manubrium  sterni,  lies  opposite  the  body  of  the  first  dorsal  vertebra 
(Plate  II.);  the  central  tendon  of  the  diaphragm  lies  opposite  the 
disc  between  the  eighth  and  ninth  dorsal  vertebne.  Its  high  jiosition 
is  probably  due  to  the  non-develo]anent  of  the  spinal  curves.  In  the 
interior  of  the  chest  it  is  noticed  that  the  sulcus  pulmonalis  on  each 
side  of  the  spine  is  shallower  and  less  capacious  than  in  later  life. 

The  external  transverse  diameter  of  the  thorax  is  not  quite  twice 
as  great  as  the  external  antero-posterior,  while  the  internal  transverse 
diameter  is  fulh'  twice  as  great  as  the  internal  antero-jiosterior :  in  the 
adult  the  transverse  is  three  times  as  great  as  the  antero-posterior. 
The  mesial  vertical  diameter  varies  from  4  cms.  anteriorly  to  C"5  cms. 
posteriorly.  All  the  diameters  are  increased  when  respiration  has 
been  established,  Init  the  antero-posterior  relatively  more  so  llian  the 
transverse  and  vertical.  The  thoracic  walls  are  flattened  somewhat 
in  the  foetus;  after  birth  they  show  a  more  maiked  external 
convexity.  A  transver.se  furrow  can  be  distinguished  which  marks 
off  the  upper  narrow  part  of  the  chest,  which  contains  the  thoracic 
viscera,  from  the  lower  broad  part  which  exjiands  over  the  upper 
aspect  of  the  abdominal  organs:  there  is  also  a  slightly  indicated 
vertical  furrow  on  each  side  which  divides  the  anterior  ]>art  of  the 
cavitv  containin"' the  heart  and  thvmus  from  the  iiosterior  containint? 


spinal  cord. 


Plate   1 

Lower  part  of  Body  o/fourth  CervictU  vertehrt 
Blood  in  spinal  canal , 


Plate  u 

upper  part  of  Body  of  first  dorsal  vertebra. 


Spimtl  cord. 


Apex  o/  Right  lung. 


Apex  o/  Left  lung. 


REGION   OF  THE  THORAX  109- 

only  the  luii,ys.  These  furrows  are  more  evident  in  fu/tuses  before- 
tlie  full  time. 

The  hones  of  the  shoulder  <;irdle  (Plate  II.)  also  occuiiy  a  higher 
position  than  in  the  adult.  Further,  the  liody  of  the  sca])ula  lies 
more  nearly  in  a  sagittal  plane  on  account  of  the  shape  of  the- 
external  aspect  of  the  thorax ;  in  this  respect  it  resendiles  the  same 
bone  in  the  quadrupeds.  It  is  also  rotated  so  that  the  "lenoid  fossa 
is  directed  markedly  upwards  and  the  inferior  angle  carried  forwards. 
The  eoracoitl  and  acromion  processes  and  the  greater  i)art  of  the- 
glenoid  fossa  lie  aboye  the  level  of  the  first  rib,  and  the  inferior  angle- 
readies  the  lower  l)order  of  the  fifth  rib;  so  that  the  whole  bone  is- 
about  one  rib  higher  than  in  the  adult.  The  result  is  that  the  outer 
end  of  the  clavicle  is  directed  upwards,  and  the  nerves  of  the  brachial! 
plexus  piass  outwards  instead  of  downwards  to  the  arm.  The  high 
fietal  p(_)sition  of  parts  reminds  us  that  the  upper  Yimh  was  at  first  a 
cervical  appendage  (Chievitz,  op.  cit.,  p.  12).  The  transverse  diameter 
of  the  shoulders  is  large :  it  is  from  12  to  14  cms.  in  the  foetus,  but 
this  measurement  is  doubtless  reduced  b}'  compaction  during  the- 
passage  of  the  infant  through  the  birth-canals ;  moreover,  the  division^ 
of  one  or  both  clavicles  (unilateral  or  bilateral  cleidotomy)  will  still 
further  diminish  this  diameter,  for  it  is  due  to  the  clavicles  that  it  is  so- 
large  and  that  the  shoulders  so  much  resist  moulding  in  laljour  (125).. 

The  sternum  occupies  a  high  level,  for  its  upper  border  lies 
opposite  to  the  first  dorsal  vertebra  or  even  to  the  disc  between  it 
and  the  seventh  cervical :  the  lower  end  of  the  liody  of  the  bone  is. 
at  the  level  of  the  fifth  dorsal  vertel.ira.  The  position  of  the  sternum 
is  remarkably  oblique,  so  that  the  distance  of  the  xiphi-sternal  joint 
from  the  spine  is  three  times  that  of  the  manubrium  from  the  spine.. 
The  shortness  of  the  anterior  chest  wall  is  largely  due  to  this- 
obliquity,  for  the  sternum  itself  is  not  short.  The  ribs  are  directed 
somewhat  more  horizontal  than  in  the  child  and  adult ;  the- 
extremities  of  the  first  three  ascend  slightly  to  their  costal 
cartilages,  those  of  the  remaining  ones,  slightly  downwards.  The- 
subcostal  angle  is  obtuse,  being  100"  in  the  foetus  as  comjiared  with 
67'  to  80°  in  the  adult. 

The  contents  of  the  thorax  are  the  thymus,  heart,  lungs,  great 
vessels,  and  oesophagus.  The  large  size  of  the  thymus  gland  (Figs.  17 
and  18,  Plate  III.)  is  one  of  the  most  striking  characters  of  the  fcEtal 
thoracic  contents.  Its  two  loljes,  right  and  left,  are  often  unequal  in 
size,  and  are  in  contact  in  the  middle  line ;  but  there  may  be  a  small 
central  lobe.  The  greater  part  of  the  gland  lies  in  the  thorax,  the  cer- 
vical part  being  almost  insignificant :  this  is  to  some  extent  due  to  the- 
high  level  of  the  thoracic  orifice  and  manulirium  sterni.  It  corresponds 
in  vertical  extent  to  the  first  four  dorsal  vertebral  bodies  posteriorly,, 
and  to  the  manulirium  and  upper  ])art  of  the  body  of  the  sternum  and 
upper  three  costal  cartilages  anteriorly.  The  thymus  rests  upon  the 
anterior  surface  of  the  pericardium,  covering  the  auricles  and  part  of 
the  ventricles  of  the  heart :  laterally  it  is  in  contact  with  the  pleura 
covering  the  lungs :  above  the  level  of  the  heart  it  rests  upon  the- 
arch  of  the  aorta,  the  innominate  artery,  the  left  innominate  vein,  audi 


no  ANTKNATAI,    I'Al'HOl.OCiY    AND    HV(;IKNK 

the  trachea.  It  may  reat'h  tlie  ilia])luai,'iii  iiiferimly.  It  has  liecu 
(lescril)ed  as  an  eloii-^ated  body  ;  hut,  in  the  fcctiis  at  any  rate,  I  have 
found  its  vertical  diameter  sometimes  not  much  longer  than  its  trans- 
verse ;  its  antero-])oslerior  measurement  is  usually  its  smallest.  It 
varies  in  weight  from  8  to  13  grms.,and  bears  a  relation  to  the  general 
body  weight  of  from  1  :2r)0  to  1 :  S'tO.  It  is  noteworthy,  as  Sehiift'er 
has  pointed  out  (loc.  cii.,  p.  591),  that  up  to  tiie  end  <jf  the  sixth  month 
of  antenatal  life  its  weight  is  to  the  body  weight  as  1 :  oOO  or  so  ;  at 
the  end  of  the  si.xth  month  it  suddenly  increases  in  weight  (1:250), 
and  retains  the  relationship  to  the  body-weight  then  assvuued  up  to 
the  end  of  fcetal  existence. 

The  heart  (Figs.  17  and  18,  Plate  III.)  is  relatively  Jicavicr  in  tlie 
fu'tus  than  in  po.stnatal  life;  the  relation  of  the  heart-weight  to  the 
general  body-weight  in  the  full-time  ftetus  varies  from  1 :  114  to  1 :211: 
in  the  adult  it  is  as  1 :  21G  (0.  Schiitt'er, /oc.  ciL,  p.  551).  It  is  situated 
more  transversely  in  the  thorax  and  at  a  somewhat  higher  level  qu<> 
the  spine.  The  upper  limit  (the  base)  I  found  to  be  the  disc  between 
the  fourth  and  fifth  dorsal  vertebne,  and  the  lower  that  between  the 
eighth  and  ninth  dorsal  vertebne.  According  to  Chievitz  {oj>.  cit.,  y. 
22),  however,  when  the  foetus  is  in  its  flexed  intra-uterine  attitude, 
the  heart  limits  are  two  hoi-izontal  planes  passing  thiough  the  tliinl 
and  seventh  dorsal  vertebra'  respectively.  The  posterior  end  of  tlu' 
lower  surface  of  the  heart  is  at  a  slightly  lower  level  than  the  anteri(  ir, 
on  account  of  the  backward  slope  of  the  diaphragm.  The  long  axis  of 
the  organ  is  placed  horizontally,  and  the  apex  is  directed  forwards 
almost  in  the  sagittal  i)lane ;  but  after  birth  it  comes  to  lie  move 
transversely  in  the  thorax,  and  the  inter-ventricular  furrow  which  had 
touched  the  chest  wall  at  the  left  margin  of  the  sternum  is  deflected 
to  a  considerable  distance  from  that  bone.  In  the  fcetus  a  great  ])art 
of  the  anterior  surface  of  the  heart  is  uncovered  l)y  the  lungs,  but  in 
the  upper  part  the  thymus  gland  intervenes  between  the  heart  and 
great  vessels  and  the  posterior  aspect  of  the  sternum  ;  the  lower  por- 
tion of  the  anterior  surface  is  separated  only  Ijy  pericardimn  from  the 
posterior  sternal  surface.  On  the  left  side  of  the  middle  line  the 
anterior  relations  are  the  costal  cartilages  and  sternal  ends  of  the 
upper  six  ribs,  with,  in  the  case  of  the  first  and  second  cartilages  and 
ribs,  the  thymus  intervening  ;  at  a  lower  level  the  pericardium  alone 
lies  between  the  heart  and  tlie  ribs,  cartilages,  and  intercostal  spaces. 
The  sharp  anterior  margin  of  the  left  lung  insinuates  itself  to  a  vary- 
ing degree  between  the  heart  and  the  left  anterior  chest  wall  (Plati' 
Hi.);  of  course,  after  l)irth  has  occurred  and  respiration  been  estali- 
lished,  this  pulmonary  insinuation  becomes  very  marked,  and  at  the 
same  time  the  anterior  margin  of  the  right  lung  comes  forward  and 
covers  the  part  of  the  anterior  surface  of  the  heart  which  lies  to  the 
right  of  the  miildle  line  of  the  sternum.  In  the  foptus,  however,  let  it 
be  borne  in  mind,  the  chief  anterior  relations  of  the  heart  are  with 
the  chest  wall  and  the  thymus.  The  heart  may  be  said  to  lie  mid- 
way between  the  cephalic  and  pelvic  extremities  of  the  foetus  ;  but 
with  regard  to  the  sjiinal  column,  its  central  point  is  nearer  the  upper 
end  than  the  lower  (Fig.  17). 


Lower  part  of  Body  of  ninth  dorsal  vertebra. 


REGION   OF   THP:   THORAX  111 

The  wall  of  the  right  ventricle  is  relatively  thick  as  compare  J 
with  the  wall  of  the  left  cavity  in  the  fcetup  (Fig.  18) ;  in  fact  it  may 
he  absolutely  as  thick  (0-5  cm.  :0'5  cm.),  it  may  even  he  thicker  (07 
cm.  :0-o  cm.).  The  surfaces  of  the  right  ventricle  meet  in  a  distinct 
margin,  which  is,  however,  more  obtuse  than  in  the  adult  lieart 
(Chievitz,  op.  cit.,  p.  22).  The  foramen  ovale  (communication  between 
the  right  and  left  auricle)  is,  save  in  quite  exceptional  and  patho- 
logical conditions,  open  in  the  full-time  foetus ;  but  both  the  valvular 
structures  (valve  of  the  fossa  ovalis  and  limbus  of  Vieussens),  which 
lead  to  its  closure,  are  easily  recognised  ;  l)y  their  union  the  foramen 
is  closed  at  a  variable  period  after  birth,  sometimes  as  early  as  the 
second  day.  During  the  last  three-and-a-half  months  of  fcetal  life 
the  valve  of  the  fossa  is  sufficiently  developed  to  prevent  the  passage 
of  blood  back  from  the  left  into  the  right  auricle.  Another  structural 
peculiarity  in  the  fa?tal  heart  is  the  ]»resence,  in  a  complete  form, 
of  the  valve  of  Eustachius,  the  crescentic  fold  of  endocardium  in  the 
right  auricle,  which  directs  the  blood  from  the  inferior  vena  cava  into 
the  foramen  ovale. 

The  lungs  (Fig.  18,  Plates  II.,  III.,  and  IV.)  occupy  a  comparatively 
narrow  space  in  the  posterior  part  of  the  thorax  of  the  fcetns  ;  the  right 
is  both  heavier  and  larger  than  the  left.  After  birth  and  the  establish- 
ment of  respiration,  all  the  pulmonary  diameters  show  an  increase,  hut 
it  would  seem  that  the  right  lung  expands  to  a  greater  extent  in  the 
antero-posterior  and  transverse  directions  than  does  the  left  (1,  p.  70). 
In  the  foetus  the  margins  of  the  lungs  are  "  sharp,  well-defined,  and 
curve  inwards  " ;  the  organs  are  of  a  "  uniformly  dense,  Hrm,  fleshy, 
and  liver-like  consistency  "  ;  they  do  not  crepitate,  little  or  no  lihiod 
oozes  out  from  an  incision,  and  no  air  bubbles  escape  when  they  are 
firmly  squeezed  under  water.  In  colour  they  are  of  a  dark  Ijrownish 
red.  All  these  characters  change  with  the  estaljlishnieut  of  breath- 
ing :  and  their  change  is  well  known  by,  and  of  great  value  to  the 
medical  jurist.  A  large  part  of  the  surface  of  the  right  lung  comes 
into  relation  with  the  thymus,  but  only  a  narrow  strip  of  the  left 
lung  above  the  level  of  the  cardiac  impression  is  in  touch  with  that 
gland. 

The  chief  peculiarity  of  the  great  vessels  of  the  thorax  in  the 
foetus  is  the  presence  of  an  open  comnnmicating  canal  between  the 
pulmonary  artery  and  the  aorta,  the  ductus  arteriosus  or  ductus 
Botalli.  From  the  posterior  end  of  the  upper  surface  of  the  heart  (as 
it  lies  in  the  foetal  thorax)  the  pulmonary  artery  arises  and  passes 
backwards  in  a  horizontal  and  nearly  sagittal  direction  ;  it  gives  off 
from  its  lower  aspect  the  right  and  left  pulmonary  arteries,  and  is 
continued  as  this  communicating  trunk  or  ductus  arteriosus  to  join 
the  aorta ;  it  is  crossed  at  the  point  of  junction  by  the  vagus  nerve. 
The  aorta  proceeds  from  the  heart  in  a  more  vertical  direction  ;  the 
highest  point  reached  by  the  arch  is  opposite  the  body  of  the  second 
dorsal  vertebra  or  the  disc  between  the  second  and  third  bodies,  and 
there  it  gives  off  the  innominate  artery  ;  it  gives  off  the  left  subclavian 
opposite  the  third  dorsal  vertebra;  and  it  is  joined  by  the  ductus 
arteriosus  opposite  the  fourth  dorsal  vertebra  where  also  the  aorta 


112  ANTKXATAl,    I'ATHOUXiV    AND    HYCilENK 

comes  iiit"  contact  with  the  spine.  Tlie  vena  cava  su])erior  is  sliort 
and  has  a  vertical  direction  ;  the  left  innominate  veui  runs  trans- 
versely -and  is  clearly  seen  (iu  vertical  mesial  sagittal  sections) 
posterior  to  the  thymus  gland  at  its  upper  part.  The  relation  of  the 
great  vessels  to  the  s])ine  alters  little  at  birth. 

If  tile  ductus  arteriosus  he  studied  more  in  detail,  it  is  found  to  he 
at  its  (jrigin  a  distinct  continuation  of  the  trunk  of  tlie  ]iulmonary 
artery.  Botli  in  direction  and  in  size  it  looks  like  the  main  trunk, 
with  the  right  and  left  ])ulmonary  arteries  as  almost  insignificant 
branches  of  it.  It  narrows  slightly  as  it  approaches  the  aoi'ta,  and 
passes  somewhat  obli(juely  through  its  wall ;  it  opens  into  the  aorta 
at  a  point  not  ijuite  opposite  to  the  point  of  origin  of  the  left  sub- 
clavian artery ;  the  orifice  of  the  ductus  is  l)ordered  by  a  valvular 
projection  of  the  aortic  wall,  with  a  sliglitly  C(jncave  free  margin  ;  and 
the  space  between  the  opening  of  the  left  subclavian  artery  and  that 
of  the  ductus  has  been  called,  and  appropriately  enough,  the  pars 
communicans  of  the  festal  circulation  (Ziegenspeck).  Strassmaun 
(Arch.  /.  Gynack.,  xlv.,  p.  408,  1894)  points  out  that  the  opening  of 
the  ductus  differs  from  all  the  other  openings  into  the  aorta  in  its 
neighbourhood,  in  being  elliptical  in  shape  instead  of  round,  and  in 
having  the  aortic  wall  in  its  vicinity  raised  in  ridges  (valvular  ]irn- 
jection)  instead  of  being  quite  smooth.  These  anatomical  peculiarities 
of  the  ductus  serve  in  some  measure  to  explain  the  manner  of  its 
closure  after  birth  {vide  infra,  Chap.  IX.). 

The  oesophagus  leaves  the  middle  line  and  inclines  to  the  left  at 
about  the  level  of  the  sixth  cervical  vertebra;  at  the  level  of  tlie 
fourth  dorsal  vertebra  it  turns  forwards  beside  tlie  aorta,  and  conies 
to  lie  in  front  of  it :  it  then  inclines  again  to  the  left  at  the  level  of 
the  ninth  dorsal  (disc  between  the  seventli  and  eighth  dor.sal,  accord- 
ing to  Chievitz),  where  it  pierces  the  diaphragm.  The  thoracic  duet 
follows  its  usual  course,  but  is  not  very  evident  in  the  foetus. 

The   Region  of  the  Abdomen. 

The  abdomen  in  the  fietus  (Figs.  17  and  18,  Plates  IV.,  V., 
VI.,  VII.,  and  VIII.)  is  large,  and  has  the  peculiarity  of  being  con- 
nected with  the  placenta  1:)V  means  of  the  umbilical  cord.  The 
umbilicus  may  be  described  as  occupying  the  central  point  of 
the  body,  half-way  between  the  vertex  and  the  heels,  or,  according 
to  my  measurements,  a  little  nearer  to  the  latter  than  to  the 
former.  The  attachment  of  the  cord  (Plate  VII.)  is  at  the 
level  of  the  disc  between  the  fourth  and  fifth  lumbar  vertebne; 
but  doubtless  considerable  variations  occur  with  the  degree  of 
distention  of  thealidominal  cavity,  etc.  On  the  internal  aspect  of  the 
anterior  alidominal  wall  the  constituent  parts  of  the  umlulical  cord  ran 
be  seen  to  break  iip  ;  the  umbilical  veiu  passes  u])wards  in  the  middle 
line  to  the  liver;  the  lu-achus  passes  downwards  in  the  middle  line  to 
the  bladder ;  and  the  two  umbilical  (hypogastric)  arteries  also  proceed 
downwards.  Init  diverge  from  the  middle  line  to  the  sides  of  the 
lilndder.  where  they  join  the  internal  iliacs,  or  rather  appear  to  lie 


Plate  v 

Upfer  margin  0/ Body  c/  tlvti/lh  dorsal  verlihra. 


Plate  vi 

Cartilage  between  Second  and  Third  lumbar  Z'ertebrae. 


'ght  kidney. 


I  Call  bladder. 


AHDOMINAI.    OUCiANS  H3 

joined  by  the  internal  iliacs,  fnr  the  latter  are  at  this  a^e  small  in 
size  in  comparison  to  them. 

When  the  foetal  abdomen  is  opened,  eertain  ontstandinj^-  peculi- 
arities are  evident  at  once.  The  great  omentum  is  markedly  trans- 
parent and  delicate  in  textm-e;  the  liver  is  very  large  (Plates  IV.,  V., 
VI.,  and  VII.)  and  appears  to  occup}' nearly  one-half  of  the  whole 
cavity :  the  left  hepatic  lobe  is  relatively  very  large,  and  hides  from 
view  the  stomach  (Fig.  18);  the  large  intestine  is  full  of  dark  green 
meconium ;  and  the  urinary  bladder  is  an  abdominal  content.  As 
Eibemont  has  shown,  a  plane  passing  along  the  inferior  surface  of 
the  liver  dix'ides  the  abdomen  into  two  compartments,  each  pyramidal 
in  form  and  nearly  symmetrical :  one  has  its  liase  above,  occupying 
the  right  hypochondrium  and  epigastric  region,  its  apex  below 
turned  towards  the  right  iliac  crest,  and  contains  the  liver ;  the 
other  has  its  base  inferior,  its  apex  turned  towards  the  posterior  part 
of  the  left  hypochondrium,  and  contains  the  intestinal  coils,  the 
spleen,  and  the  stomach. 

The  liver,  as  has  been  stated,  is  large,  very  large,  in  the  fai'tus : 
but  in  the  full-time  foetus  it  is  not  relatively  so  large  as  in  the 
earlier  months ;  its  weight  is  to  the  body-weight  as  1:15  or  1 :  16, 
and  in  the  full-time  foetus  as  1:18  or  1:19.  The  form  of  the  fcetal 
liver  has  been  made  clear  chiefly  by  the  study  of  frozen  sections.  It 
has  five  (sometimes  six)  surfaces :  there  is  a  superior  surface  iu 
contact  with  the  lower  surface  of  the  diaphragm  to  which  it  is 
accurately  moulded,  generally  convex  but  with  a  localised  concavity 
corresponding  to  the  heart ;  an  anterior  surface  in  contact  with  the 
anterior  aliiliiHiinal  wall,  having  a  quadrangular  shape  (triangular  iu 
the  adult),  and  sharply  marked  oH'  from  the  left  inferior  siu'face  by 
the  thin  anterior  border ;  a  right  lateral  surface,  less  clearly  de- 
limited ;  a  posterior  surface,  small  in  extent,  very  evident  in  sagittal 
sections,  inclmling  the  notch  for  the  cesophageal  end  of  the  stomach, 
the  posterior  part  of  the  longitudinal  fissure,  the  groove  for  the  vena 
cava  inferior,  and  the  lobus  Spigelii ;  a  left  inferior  surface,  marked 
off' from  the  others  by  the  anterior  border  and  by  the  groove  anterior 
to  the  lobus  Spigelii,  of  considerable  extent,  showing  the  impressions 
left  upon  it  by  the  various  organs  which  come  in  contact  with  it, 
being  made  up  of  the  under  surfaces  of  the  right  and  left  lobes 
and  of  the  quadrate  and  caudate  loljes,  and  being  ti'aversed  by  the 
longitudinal  and  transverse  fissures  and  the  fissure  for  the  gall- 
bladder ;  and  an  ill-defined  left  surface  which  in  later  life  is  merged 
with  the  superior  surface.  Of  all  these  sui'faces  the  anterior  and 
left  inferior  are  the  largest,  and  then,  in  order,  come  the  superior, 
right,  and  posterior.  The  whole  organ  is  "  a  right-angled  triangular 
prism  with  the  right  angles  rounded  off',"  sometimes  it  is  a  trape- 
zoid (Mettenheimer,  loc.  cit.,  p.  337).  The  gall-liladder  lies  about 
1'5  cm.  to  the  right  of  the  middle  line,  is  more  cylindrical  in  form 
than  in  later  life,  and  is  distended  with  bile. 

The  stomach  (Fig.  18,  Plates  IV.  and  V.)  is  small  in  size  at  birth, 
and  can  contain  only  about  1  or  lA  fl.  oz.  without  being  over-disteuded. 
The  fundus  is  relatively  small,  and   the   lesser  curvature   forms  a 


114  ANTKNATAI,    I'ATHOI.OdY    AND    HYCIF.NI'. 

more  acute  au.^le  than  in  imslnatal  life.  At  liirth  the  viscus  may  he 
empty,  or  it  may  cnntain  a  ihiid  like  li([U(>r  amnii ;  in  one  case  in 
which  labour  had  heen  instrumental,  I  found  some  meconium  in  it. 
It  lies  under  cover  of  the  left  lolie  of  the  liver,  and  doe.s  not  extend 
to  the  right  of  the  middle  line  of  the  ])ody,  the  p3'lorus  being  situated 
immediately  in  front  of  the  body  of  the  fir.st  lumbar  vertebra  (lower 
border  of  ninth  dorsal,  according  to  Chievitz).  The  anterior  relations 
of  the  fcetal  stomach,  therefore,  are  with  the  left  inferior  surface  of 
tlie  liver;  while  posteriorly  it  is  in  contact  from  above  downwards 
with  the  anterior  surface  of  the  spleen,  the  left  supra-renal  cajisule, 
tlie  upper  end  of  the  left  kidney,  and  with  the  tail  and  body  of  the 
pancreas.  Below  the  greater  curvature  is  the  transverse  colon ;  the 
lesser  curvature  runs  first  parallel  to  the  left  side  of  the  vertebral 
column,  and  then  passes  transversely  to  the  right  side  in  front  of  the 
spine. 

The  pancreas  in  the  fa>tus  weighs  about  4'5  grammes,  and  is  to  the 
total  body  weight  as  1  :  700  or  thereljy ;  it  measures  about  3'5  cms.  in 
length,  and  its  antero-posterior  diameter  in  the  middle  line  is  aliout 
1  cm.  It  lies  opposite  the  first  and  second  lumbar  vertebrae  It  has 
practically  the  same  relations  with  surrounding  j)arts  as  in  postnatal 
life,  but  does  not  come  into  immediate  contact  with  the  left  kidney. 

The  spleen  (Plate  IV.)  lies  almost  horizontal  with  the  foetus  in  the 
intrauterine  attitude  of  flexion,  and  is  opposite  to  the  eighth,  ninth, 
and  tenth  dorsal  vertebrje.  The  liver  comes  into  contact  with  it 
behind  and  external  to  the  stomach,  and  it  has  a  direct  relationship 
with  the  left  supra-renal  capsule  instead  of  with  the  left  kidney.  It 
has  therefore  four  instead  of  three  surfaces :  a  phrenic  posteriorly ; 
a  gastric  or  antero-internal  which  is  in  contact  with  the  tail  of  the 
pancreas  as  well  as  with  the  stomach  ;  a  supra-renal  inferiorly  ;  and 
a  hepatic  anteriorly.  Near  the  middle  Hue  the  spleen  sIkiws  only 
three  surfaces  on  section,  phrenic,  gastric,  and  supra-renal. 

The  intestinal  canal  (Figs.  17  and  18,  Plates  V.,  VI.,  VII.,  VIII.,  and 
IX.)  increases  remarkably  in  length  during  tVTtal  life;  the  increase  is 
also  continuous;  and  at  the  tenth  month  the  total  length  is  410  cms. 
or  so  (Merkel,  op.  cit.,  p.  22),  the  addition  during  the  last  month  ha\'ing 
been  25  per  cent.  No  doulit  there  are  great  individual  variations. 
With  regard  to  the  small  intestine  a  few  words  of  description  will 
suffice.  The  duodenum  commences  at  the  pyloric  end  of  the  stomach, 
opposite  the  first  lumbar  vertebra :  there  it  crosses  to  the  right  side 
of  the  l)ody,  its  third  part  crossing  over  again  to  the  left  side  of  the 
spine  at  the  level  of  the  second  lumbar.  According  to  Chievitz  {ojh 
cit.,  p.  33),  the  levels  are  the  tenth  dorsal  and  the  first  lumbar.  The 
jejunum  and  ileum  are  less  fixed  in  position  than  the  duodenum  ; 
the  line  of  attachment  of  the  mesentery  is  nearly  horizontal :  and 
the  coils  of  intestine  follow  one  another  progressively  from  left  to 
right.  There  is  usually  little  meconium  in  the  small  intestine.  The 
ciecum  may  be  found  occujiying  its  adult  position  in  the  right  iliac 
and  right  lumbar  regions,  with  the  ileum  entering  it  at  the  ileo-ca'cal 
valve  aliout  the  level  of  the  right  iliac  crest  or  a  few  mms.  above  it ; 
but  I  have  met  with  several  cases  in  which  this  part  of  the  large 


Plate  '."ir 


spinal  cord. 


Body  o/Jirtt  sacral  vertebra. 
Psoas  {ie/t). 


^Lpop  o/sigitwid 


ABDOMINAL   OKdANS  115 

intestine  lay  at  a,  considerahly  higher  point  in  the  aluliinien,  and  one, 
at  least,  in  which  it  oecnpied  the  niidtlle  line  inuuediately  l)ehind  the 
ninbilicus,  positions  which  recall  the  changes  which  occur  during 
development.  It  is  probable  that  the  ciccuni,  in  the  full-time  fcetns, 
has  not  always  reached  its  permanent  position.  The  appendix 
verniiformis  is  well  marked  at  this  time  in  life ;  it  comes  off  in  a 
conical  form  from  the  Ciccuni ;  measures  from  3  to  4  cms.  in  length ; 
and  has  a  thin  mesentery  attaching  it  to  the  bowel.  The  ascending 
colon  may  pass  upwards  to  the  under  surface  of  the  right  lobe  of  the 
liver  and  form  there  a  distinct  hepatic  Hexure,  liut  often  its  course  is 
a  very  short  one  and  the  flexure  very  feebly  marked.  The  trans- 
verse colon  has  not  a  direction  so  definitely  transverse  as  in  later 
life,  and  not  infrequently  forms  a  wide  loop  passing  downwards 
towards  the  pelvic  lirini.  The  descending  colon  has  a  similar 
arrangement  to  that  seen  in  the  adult ;  but  the  sigmoid  flexure 
is  of  relatively  great  length,  and  generally  forms  a  large  loop,  part 
of  which,  in  the  male  fa'tus  at  any  rate,  lies  in  the  posterior  part  of 
the  pelvic  cavity ;  there  is  often  a  rather  long  meso-sigmoid.  The 
large  intestine  in  the  fcctus  is  distended  with  meconium.  The  length 
of  the  whole  bowel  is  to  that  of  the  fcetal  body  as  570  :  100  ;  in  adult 
life  the  relation  is  as  450  :  100. 

The  sujjra-renal  capsules  (Fig.  18,  Plate  V.)  are  relatively  large  in 
the  full-time  foetus,  each  being  equal  in  size  to  one-third  of  the 
kidney.  The  weight  of  both  together  is  from  7  to  8  grannnes,  and 
their  relation  to  tlie  general  body -weight  is  as  1:400  (circa). 
According  to  0.  Scliiiffer  (loc.  cif.,  p.  532),  the  right  capsule  is  larger 
than  the  left  in  the  tenth  month  of  antenatal  life,  while  in  the 
earlier  months  the  left  is  larger  than  the  right.  They  have  the  form 
of  a  triangular  pyramid,  and  each  rests  upon  the  upper  end  of  the 
kidney,  covering  it  like  a  cap  ;  the  base  descends  upon  the  anterior 
renal  surface  as  low  as  the  level  of  the  hilum,  and  is  hollowed  out  to 
fit  its  convexity.  The  apex  of  the  right  adrenal  lies  between  the 
liver  and  the  right  crus  of  the  diaphragm,  at  about  the  level  of  the 
tenth  rib  ;  that  of  the  left  is  wedged  in  between  the  spleen  and 
the  left  diaphragmatic  crus,  at  a  point  a  little  above  the  level  of  the 
eleventh  rili.  The  posterior  surface  rests  upon  the  diaphragm  at  the 
side  of  the  vertebral  column.  Anteriorly  the  right  adrenal  comes 
into  contact  with  the  left  inferior  surface  of  the  liver,  and  with  its 
posterior  surface  ;  the  left  supra-renal  gland  is  related  to  the  spleen, 
stomach,  pancreas,  and  small  intestine. 

The  kidneys  (Fig.  18,  Plates  V.  and  VI.)  correspond  in  level  with 
part  of  the  vertebral  column  lying  between  the  disc  between  the  twelfth 
dorsal  and  first  lumbar  vertebne,  and  that  between  the  third  and 
fourth  lumbar  vertebrte.  In  the  full-time  foetus  the' left  kidney  is 
usually  longer  than  the  right,  but  this  is  not  an  invarialile  rule. 
Each  weighs  about  11  grannnes ;  and  their  joint  weight  is  to  the 
general  Ijody-weight  as  1 :  130  (circa),  in  the  adult  it  is  as  1 :  225. 
The  hilum  lies  at  the  level  of  the  second  lumbar  verteljra.  In  the 
full-time  fcetus  the  renal  lobulation  is  still  evident,  but  is  not  so 
marked  as  in   earlier  antenatal  life.     The  kidneys  have  much  the 


116  ANTENATAL    I'ATHOLOCiY   ANT)    HY(;1KNK 

same  relations  with  other  viscera,  save  in  so  far  as  tliey  are  more 
extensively  covered  l)y  the  supra-renal  cajjsules.  Tlie  ureters  ])ass 
downwards  and  inwards  forming  a  curve,  with  siigiit  LMjnvexity 
towards  the  middle  line,  and  ojien  into  the  Idadder  at  or  immediately 
aliove  the  ]ielvic  brim.  Tlie  relation  of  the  ureteric  o])eiiings  to  the 
plane  of  the  l)rim  is  due  to  the  fact  that  in  the  fo'tus  the  bladder 
(Plate  Vlll.)  is  almost  entirely  an  abdominal  organ.  In  the  case  of 
two  full-time  male  fretuses  (examined  by  me)  in  which  the  liladder 
contained  nrine,  a  small  part  of  the  jiosterior  lower  portion  lay 
below  the  brim ;  in  three  full-time  female  fcetuses,  in  which  the 
viscus  was  empty,  an  almost  inappreciable  part  lay  lielow  the  brim. 
The  position  of  the  u])per  end  of  the  bladder  varies  with  the  degree 
of  distension:  when  empty,  I  have  noted  it  about  2'5  cms.  al]0ve  the 
symphysis  pubis,  and  when  full  as  high  as  a  few  mms.  above  the 
umbilicus  at  one  side  thereof.  The  form  of  the  empty  bladder  is 
simply  that  of  a  tube  continuing  the  urethra ;  when  nujderately  full 
it  has  an  ovoid  shape,  the  broad  end  being  du-ected  downwards  and 
Ijackwards :  and  when  greatly  distended,  an  ovoid  with  the  broad 
end  uppermost.  The  anterior  vesical  wall  is  in  close  contact  with 
the  anterior  abdominal  w"all,  and  there  is  no  intervening  pouch  of 
peritoneum.  Posteriorly  the  peritoneum  passes  over  the  liladder 
wall,  reaching  in  the  male  foetus  to  a  level  immediately  below  that  of 
the  vesical  orifice,  and  here  comes  into  relation  with  the  small 
prostate  gland;  in  the  female  foetus  it  does  not  descend  so  low- 
posteriorly,  its  point  of  reflexion  on  to  the  anterior  urine  wall  being 
above  the  level  of  the  internal  urethral  orifice.  The  organs  that  lie 
posterior  to  the  bladder  in  the  male  fcetus  vary  :  in  some  cases  a 
loop  of  sigmoid  lies  Ijehind  it;  in  other  instances,  some  coils  of  small 
intestine ;  and  in  yet  others,  simply  the  rectum,  the  intervening 
pouch  of  peritoneum  being  empty. 

The  bifurcation  of  the  abdominal  aorta  takes  place  opposite  the 
third  lumbar  vertebra  (Chievitz,  o/;.  cif.,  p.  38).  The  umbilical 
arteries,  in  their  curved  course  from  their  origin  in  the  internal 
iliacs  to  the  anterior  abdominal  wall,  lie  entirely  aliove  the  plane  of 
the  brim;  they  ai-e  so  large  in  the  fietus  as  to  look  like  direct  con- 
tinuations of  the  internal  iliacs,  even  of  the  common  iliacs ;  in  their 
abdominal  part  thej'  are  commonly  called  hypogasti'ic  arteries,  and 
in  their  funic  part,  umbilical ;  the  portion  of  each  hypogastric  wliich 
remains  pervious  after  the  readjustment  changes  of  l.iirth,  is  the 
superior  vesical  artery. 

The   Region  of  the  Pelvis. 

The  region  of  the  jielvis  (Plates  VIII.  and  IX.)  is  comparatively 
poorly  develojied  in  the  full-time  fictus.  It  has  been  already  noted 
that  the  bladder  is  an  abdominal,  not  a  jielvic,  organ  at  this  time  of 
life,  and  the  same  statement  has  now  to  be  made  about  the  uterus,  the 
Fallojiian  tubes,  and  ovaries ;  the  reason  is  that  the  pelvis  is  not  yet 
capacious  enough  to  contain  all  the  structures  which  afterwards  lie 
within  it. 


Plate   ix 


third  coccygeal  Vertebra. 


THK   PELVIS 


ir 


The  sacrum  is  qixite  straight,  or  lias  ouly  a  slight  anterior  cdu- 
cavity  in  the  foetus.  Its  wings  are  little  developed,  so  that  the  length 
of  the  bone  is  greater  than  its  lireadth,  dolichohieric,  and  the  sacral 
index  76'  ;  but,  while  this  is  the  generally  accepted  statement,  A. 
Thomson  (loc.  cit.,  p.  372)  has  asserted  that  it  is  platyhieric  with  an 
index  of  100°.  The  iliac  bones  have  an  almost  inappreciable  anterior 
concavity,  and  their  angle  of  divarication  is  large.  The  pubic  l)(ines 
are  stumpy,  and  the  symphysis  is  short.  The  interspino\is  diameter  of 
the  false  pelvis  may  be  given  as  5'5  cms.,  and  the  intercristal  as  6  cms. 

The  foetal  characters  of  the  true  pelvis  are  interesting.  The  canal  is 
somewhat  funnel  shaped,  and  the  pelvic  brim  is  very  olilicpie  to  the 
horizon,  a  character  due  to  the  higli  level  at  which  the  promontory  lies 


Fig.  21. — Vei'tical  sagittal  section  of  peh-ic  region  of  full-time  male  fcetus 
(section  slightly  to  right  of  middle  line  anteriorly),  a,  Anal  aperture  ;  b, 
bladfler,  gi'eatly  distended  with  urine  ;  c,  opening  of  left  ureter  ;  d, 
vesical  trigone  ;  c,  loop  of  sigmoid  flexure  in  jielvis  ;  /,  rectum  ;  i/,  coccyx  ; 
h,  third  sacral  vertebra  ;  i,  jirostate  gland. 

aliove  the  symphysis.  The  plane  of  the  pelvic  outlet  is  practically  parallel 
to  the  horizon.  With  regard  to  the  pelvic  measurements  in  the  fcetus, 
somewhat  conflicting  statements  are  to  be  found.  It  seems  generally 
to  have  l.ieen  accepted  that  at  this  time  in  life  the  antero-posterior 
diameter  at  the  brim,  instead  of  l)eing  less,  is  greater  than  the  trans- 
verse ;  Ijut  both  Sir  William  Turner  and  A.  Thomson  have  found  that 
the  foetal  pelvis  is  platypellic,  and  does  not,  therefore,  ditler  in 
this  respect  from  the  adult.  In  my  own  observations  I  found  that 
while  the  diameter  from  the  promontory  to  the  symphysis  had  always 
a  greater  length  than  the  transverse,  that  from  the  upper  border  of 
the  third  sacral  vertebra  to  the  symphysis  (which  more  truly  corre- 
sponds to  the  antero-posterior  in  the  adult)  was  sometimes  less  than 


Lliu  transverse,  iuul  only  occasioiiiilly  ,i;reater  than  the  latter  diameter. 
It  must  therefore  be  cunchuled  that  the  antern-posterior  diameter  at 
the  true  pelvic  brim  is  not  constantly  longer  than  the  transverse  in 
tlie  fojtus.  As  a  matter  of  fact  I  found  the  ol)li([ue  diameter  to  be 
the  longest  at  the  brim.  An  interesting  point  in  tiiis  relation,  which 
has  lieen  emphasised  by  A.  Thomson  (kic.  ciL,  ]>.  -"iGS),  is  that  even  in 


Fig.  i2. — Vortical  sagittal  .section  ol'pelvi(^  ivgion  of  full-time  female  fcetiis  (fiozeii  in 
geuu-pectoral  position),  a,  Coecvx  ;  h,  first  sacral  vertebra  ;  c,  liodj-  of  uterus  ; 
(/,  cervix  uteri ;  c,  vagina  ;/,  empty  bladder  ;  r/,  symphysis  pubis  ;  h,  riglit  ovary 
and  Fallopian  tube  ;  i,  rectum  ;  I:,  anal  aperture. 

foetal  life  the  pelvis  shows  in  its  diameters  and  other  characters  the 
pecidiarities  that  (hstiiiguish  the  male  from  the  female  skeleton  ;  thus 
the  male  ])elvis  has  a  more  funnel  shape  than  the  female,  the  ischial 
spines  are  more  inturned  (bi-ischial  diameter  iu  male  fu'tus,  12  mms., 
in  female,  14  mms.),  the  suli-pubic  angle  measures  in  the  male  50°, 
and  in  the  female  68°,  and  the  sacro-sciatic  notch  and  hinder  part  of 
the  ilium  are  nairower  in  the  male  than  in  the  female.       The  last- 


PELVIC   ORGANS 


119 


named  iioint  has  a  further  interest,  for  Thomson  beheves  that  the 
increase  in  width  of  the  jielvic  brim  and  cavity  which  occurs  in  post- 
natal life  is  due  not  to  transverse  growth  of  the  sacrum,  liut  to  growth 
of  the  posterior  parts  of  the  ilia,  and  that  this  holds  for  both  sexes. 
It  may  thei'efore  be  concluded  that  the  foetal  pelvis  does  not  ditt'er  so 
much  from  the  adult  type  as  has  lieen  supposed,  and  that  the  sexual 
characters  are  all  present  before  l)irth.  In  the  adult  the  ilia  are  pro- 
portionately wider  than  in  the  foetus  ;  this  is  i-eally  tlie  one  outstanding 
character  in  which  the  fcetal  pelvis  differs  from  the  adult,  and  it  serves 
to  account  for  the  altered  relations  of  the  viscera. 

The  pelvic  viscera  in  the  male  fa^tus  (Fig.  21)  are  the  rectum, 
the  prostate,  and  a  loop  of  sigmoid  flexure.  The  rectum  is  relatively 
larger  and  more  vertically  placed  in  the  foetus  than  in  the  adult ;  it 
is  more  nearly  straight.  The  peritoneum  descends  in  front  of  this 
part  of  the  intestine  to  the  level  of  the  fourth  sacral  vertebra.  The 
position  of  a  loop  of  sig- 
moid flexure  in  the  pelvis 
has  been  already  referred 
to. 

In  the  pelvis  of  the 
female  fcetus  (Fig.  22)  the 
lower  part  of  the  uterus  ,, 
constitutes  an  additional  \ 
content,  but  a  certain  part 
of  that  organ,  with  the 
ovaries  and  Fallopian 
tu1)es,  lies  above  the  plane 
of  the  brim  and  is  there- 
fore  abdominal.     From    a 

third  to  fully  a  half  of  the  Fig.  23.— Dissectional  view  of  pelvic  viscera  in  six- 
entire   uterine    length    lies  months  fcetus  tVom  above  and  from  the  front,    a, 
above   the    1  )rim  ;    possibly  ^'^''^''''  V*'  5""4;'.^  "'eri ;  c   left  Fallopian  tube, 
',."             ",  showing  tortuosities;  d,  left  ovary  ;  c,  rectum. 

the    empty   or    distended 

condition  of  the  bowel  may  account  for  variations.  The  body  of 
the  uterus  generally  lies  forward  upon  the  posterior  aspect  of  the 
bladder ;  in  one  of  the  cases  which  I  examined  there  was  a  certain 
amount  of  uterine  torsion,  so  that  the  anterior  surface  looked  towards 
the  left  as  well  as  the  front,  a  condition  due  possibly  to  the  presence 
of  a  loop  of  sigmoid  in  the  right  lateral  pouch  of  Douglas.  The 
cervix  uteri  is  relatively  thicker  and  longer  than  the  corptis  ;  in  the 
uterine  interior  the  folds  of  the  arbor  vitic  are  prolonged  to  the 
fundus  ;  the  os  is  not  uncommonly  gaping ;  and  some  rugai  may  be 
seen  on  the  vaginal  aspect  of  the  cervix,  especially  on  the  anterior 
lip.  The  Fallopian  tubes  (Fig.  23)  measure  about  2-5  cms.  in  the  full- 
time  foetus,  each  has  from  three  to  five  sinuosities  on  it,  and  each 
runs  outwards,  backwards,  and  downwards  to  the  level  of  the  pelvic 
Ijrim  (3).  The  ovaries,  also,  lie  aliove  the  brim  ;  they  have  an  elong- 
ated, almost  cylindrical  form  ;  and  they  show  on  section  a  very  large 
number  of  ovi-sacs.  The  vaginal  canal  is  another  pelvic  content  of  the 
female  fcetus  ;  in  fact,  in  sagittal  sections  it  appears  as  if  it  were  almost 


120  ANTENATAL   PATHOl.OCiV   AND   HYCIKNE 

the  only  pelvic  content.  It  has  a  relatively  great  length  ;  in  its  uiiper 
])ortion  it  has  an  almost  vertical  direction,  Init  in  its  lower  ]>:nt  it 
runs  downwards  and  slightly  forwards  ;  and  its  walls  are  covered  with 
numerous  ruga^  Tiic  urethra  in  the  female  fcetus  is  about  4  cms.  in 
length,  and  ahout  6  cms.  in  liie  male  ;  in  the  former  se.x  it  terminates 
at  the  meatus  uriuarius  externus,  aliout  1  cm.  in  front  of  a  line  drawn 
vertically  downwards  from  the  lower  border  of  the  symphysis  puliis. 
Between  the  meatus  and  the  liase  of  the  clitoris  may  be  .seen  a  ridge, 
the  male  vestibular  band  (18).  With  regard  to  the  external  ajipear- 
ances  of  the  pelvic  end  of  the  foetus,  it  is  to  lie  noted  that  the  external 
genital  organs  in  both  sexes  are  somewhat  incompletely  developed  as 
compared  witli  the  later  life.  Tlie  labia  majora,  for  instance,  are  relat- 
ively small,  and  therefore  tiie  labia  minora  and  other  jjarts  are  less 
concealed  from  view  than  in  the  adult.  On  account  of  the  slight 
development  of  the  gluteal  regions  in  the  foetus,  there  is  a  lack  of  the 
distinct  groove  between  the  buttocks  which  exists  in  later  life,  and  si  > 
the  anal  aperture  may  seem  to  be  situated  on  an  elevation  rather 
than  in  a  depression. 

The  Extremities. 

Both  the  upper  and  lower  limbs  of  the  fcetus,  liut  the  lower  more 
than  the  upper,  are  relatively  small.  Further,  the  ossification  of  the 
limb  bones  is  not  yet  far  advanced  (Lambertz,  op.  cit.) ;  but  there  is 
great  vascularity  in  tlie  cartilage,  in  the  o-sseous  tissue,  and  in  the 
bone-producing  periosteum.  The  marrow  is  red.  The  limbs  are 
disposed  in  a  natural  attitude  of  flexion  in  utero,  and  the  feet  are  so 
placed  as  to  look  as  if  there  were  talipca  varus,  l)ut  there  is  of  cour.se 
no  real  club  foot  in  normal  circumstances.  The  muscles  of  the 
fcetus  are  softer  than  those  of  the  child  or  adult;  and  Chievitz 
(op.  cit.,  p.  12)  has  pointed  out  that  they  all  pursue  a  straight  course. 

The   Umbilical  Cord. 

The  umbilical  cord  or  funis  is  the  organ  of  communication  between 
the  foetal  body  and  the  fcetal  part  of  the  placenta.  It  is  therefore  a 
festal  structure  in  its  entirety,  for  even  its  sheath,  which  used  to  be 
regarded  as  amniotic  in  nature,  is  now  known  to  be  by  develojiment 
foetal  skin  (Minot,  Human  Umbri/oloi/r/,  p.  362,  1892  ;  Foulis,  J., 
Trans.  Mcd.-Chir.  Soe.  Edinh.,  xix.,  p.  164,  1900). 

The  unil)ilical  cord  has  an  average  lengtli  of  about  20  inches  (45 
to  00  cms.),  but  it  varies  witliin  wide  limits.  In  tliickiicss  it  is  com- 
parable to  the  little  finger,  lint  again  there  are  wide  dilferences  in 
measurement :  the  degree  of  thickness  will  depend  in  great  part  u])on 
the  amount  of  nnicoid  tissue  in  its  structure.  It  is  wliite  and  cord- 
like in  appearance,  and  through  the  glistening  sheath  the  vessels  are 
shadowed  forth  as  liluish  streak.s.  Like  a  cord  of  rope,  it  is  rounded 
without  being  (|uite  cylindrical,  f<n-  it  is  twisted  <ui  itself.  Looking 
from  the  ftetal  undiilicus  towards  tlu']ilacental  end  of  the  funis,  it  can 
be  seen  that  in  most  cases  the  twist  is  from  right  to  left  ovei"  the 


UMBILICAL   CORD  121 

anterior  surface  of  the  cord,  then  round  tlie  left  side  to  tlie  posteri(jr 
aspect,  and  from  left  to  right  over  it  to  reach  again  tlie  anterior  sur- 
face ;  rarely  the  spiral  is  in  the  opposite  direction.  The  various 
structures  in  the  cord  are  not  equally  twisted,  for  the  arteries  are 
coiled  round  the  vein  (Tarnier),  and  the  total  number  of  twists  varies 
from  or  two  to  twenty  or  even  more,  but  the  large  numbers  are 
pathological.  Here  and  there  on  the  cord  may  sometimes  be  recog- 
nised swellings  or  nodosities  (false  knots)  due  to  localised  excess  of 
mucoid  tissue  or  to  torsion-anomalies  of  the  ves.sels  (Thonia,  E.,  Arcli. 
/.  Gynaek.,  Ixi.  p.  36,  1900).  Many  so-called  explanations  have  been 
advanced  to  account  for  the  twisting  of  the  cord,  l)ut  none  of  them 
has  been  generally  accepted  ;  all  that  it  seems  safe  to  assert  is  that 
the  vessels  grow  faster  than  the  cord  as  a  whole,  which,  therefore,  has 
to  l)e  disposed  in  a  spiral  fashion.  The  cause  of  the  unequal  rate  of 
grcjwth  is  unknown.  The  foetal  insertion  of  the  cord  (proximal  end) 
has  been  considered  :  at  its  placental  or  distal  end  the  funis  is 
attached  to  the  foetal  surface  of  the  placenta  at  a  point  not  quite  cor- 
responding with  the  centre  of  that  siirface,  but  lying  a  little  eccentric 
to  it ;  there  the  cord  fuses  with  the  ftetal  part  of  the  placenta,  and  its 
sheath  becomes  continuous  with  the  amnion,  covering  the  foetal 
surface.  The  cord  may  shnply  lie  beside  the  foetus,  within  the 
maternal  uterus  (in  the  cavity  of  the  amnion),  or  it  may,  especially  if 
it  be  of  considerable  length,  lie  disposed  in  the  form  of  one  or  more 
convolutions  round  the  foetal  body  or  limbs. 

In  the  full-time  fcetus  the  structure  of  the  cord  is  comparatively 
simple.  The  sheath  consists  of  a  stratified  epithelium  :  the  outer 
layer  of  cells  is  corneous,  and  may  show  stomata  ;  there  is  a  middle 
layer  of  clear  cells ;  and  beneath  that  a  basal  layer  of  granular  cuboidal 
cells  (Minot).  Before  the  fifth  month  the  outer  layer  is  made  np  of 
dome-shaped  cells,  and  probably  corresponds  to  the  epitrichium  of 
the  skin.  It  may  be  said  that  the  sheath  of  the  cord  is  composed  of 
skin,  but  skin  which  has  not  passed  the  stage  which  it  reaches  at  the 
fourth  month  of  intrauterine  life.  The  fully  developed  epidermis  of 
the  fatal  abdomen  extends  for  the  distance  of  1  cm.  on  to  the  cord, 
where  it  becomes  continuous  with  the  sheath  ;  at  the  placental  end 
the  latter  merges  with  the  amnion  covering  the  placenta.  Within 
the  sheath  the  vessels  of  the  cord  are  held  together  by  a  mucoid  or 
embryonic  connective  tissue,  Wharton's  jelly,  as  it  is  called ;  this 
consists  of  anastomosing  cells  and  a  muciparous  matrix  with  connective 
tissue  filjres  (fcetal  mesoblast) ;  these  parts  (cells  and  fibres)  tend  to 
arrange  themselves  in  a  concentric  fashion  round  the  three  lilood 
vessels,  forming  more  or  less  marked  systems  ;  and,  where  the  systems 
touch,  the  cells  are  triangular  in  shape,  columns  of  these  cells  being 
found  in  the  funis.  Embedded  in  the  jelly  of  Wharton  a  group  of 
epithelioid  cells  with  irregular  granular  contents  can  usually  be 
recognised ;  this  represents  either  the  yolk-stalk  or  the  allantoic 
cavity  of  early  intrauterine  life,  but  which  it  is  not  quite  safe  to  say. 
The  ves.sels  of  the  full-time  cord  are  three  in  number,  two  umbilical 
arteries  (allantoic  in  origin),  and  one  umliilical  vein  (persistent  left 
allantoic  vein).      The  structure  of  the  umbilical  vessels  is  peculiar ; 


122  ANTKXATAL   PATH()IX)(;V   AND    HYCilENE 

they  are  coniposeil  jilinost  entirely  of  a  middle  or  iiiii.seular  cuat,  being 
therefore  sinii)ly  iini.scular  tubes.  There  is  indeed  a  tunica  intinia, 
but  it  is  rudimentary  in  nature  ;  and  of  the  tunica  adventitia  there  is 
no  ti'ace  at  all,  the  outer  surface  of  the  muscular  coat  passing  insen- 
sibly into  the  surrounding  Wharton's  jelly.  Tliere  is  no  elastic  tissue, 
and  the  muscle  fibres  run  in  various  directions,  although  the  inner- 
most layer  shows  a  general  longitudinal  arrangement.  Valves  have 
been  described  in  both  the  vein  and  the  arteries :  they  are  more 
constant  in  the  latter  than  in  the  former,  and  are  semi-lunar,  or,  more 
rarely,  diajihragmatic  in  shape.  The  calil)re  of  the  vein  is  greater 
than  that  of  the  arteries,  but  the  walls  are  of  almost  the  same  thick- 
ness :  there  are  no  vasa  vasorum.  There  are  no  lymphatics  in  the 
cord  ;  nerves  have  been  described  in  it,  but  even  if  tiiey  are  present 
they  do  not  proceed  far  from  the  ftetal  insertion.  The  funis  will  bear 
a  weight  of  from  5  to  10  kilos,  without  breaking ;  rupture,  when  it 
occurs,  is  near  to  the  placental  end. 

The  Placenta. 

By  means  of  the  umljilical  cord  the  corporeal  part  of  the  foetus  is 
connected  with  tiie  great  extra-corporeal  organ,  the  pjlacenta.  Tbc 
placenta  is  in  part  fcctal  and  in  part  maternal  in  composition.  Tin' 
foetal  portion  consists  of  the  vessels  of  the  cord,  which  have  suli- 
divided  over  and  over  again,  and  are  spread  out  in  an  umlirella-like 
fashion  over  tlie  mucous  membrane  of  the  uterus  of  the  mother  in 
that  part  of  its  area  which  is  called  decidua  serotina  or  utero-placental 
decidua.  On  the  one  side  (foetal  aspect)  of  this  expansion  of  the 
funic  blood  vessels  is  the  amniotic  membrane,  while  on  the  other 
side  (maternal  or  uterine  aspect)  is  the  chorion.  But  while  the 
amnion  forms  a  simple  covering  membrane  for  the  placenta  on  the 
side  next  to  the  fcjetus,  the  chorion  is  greatly  expanded  in  a  series  of 
more  or  less  jjranched  processes,  the  villi,  some  of  which  serve  as 
coverings  for  the  suljdivisions  of  the  funic  vessels,  and  others  simjily 
pass  across  the  intervening  intra-]  dacental  space  to  attach  the  fa>tal 
to  the  maternal  p)art  of  the  placenta.  Further,  from  the  decidua 
serotina,  processes  or  septa  pass  in  the  opposite  direction  across  the 
intra-placental  space  towards  the  fo'tal  aspect  and  subdivide  that 
space  into  compartments.  In  this  way  the  intra-placental  space  is 
divided  up  into  smaller  cavities  both  by  the  attaching  villi  of  the 
chorion  and  by  the  septa  arising  from  the  decidua ;  into  these 
cavities  or  intervillous  spaces  hang  the  vascular  villi.  The  contents 
of  the  intervillous  space  consist  of  maternal  blood ;  the  blood  in  the 
vessels  of  the  villi  is  fiptal  l)lood:  and  in  this  manner  the  maternal 
and  fuBtal  blood  are  brought  into  close  relationship  liut  do  not  actu- 
ally mix. 

The  life-history  of  the  placenta  is  a  short  one,  for  it  is  formed  at 
the  third  month  and  its  existence  ends  with  the  birth  of  the  fcetus ; 
])ut  in  its  short  life  it  plays,  as  will  be  seen  when  the  ]ihysiology  of 
the  fuitus  is  considered,  a  very  important  part.  The  full-time  human 
placenta  is  a  spongy  mass,  meta-discoidal  in  shape,  measuring  about 


I'l.ACI'ATA  123 

seven  inches  in  diaineter,  and  from  tvvo-tbiids  of  an  inch  to  one  incli 
in  thickness,  and  weighing  about  one  pound.  Tlie  side  of  this  dis- 
cdidal  mass,  wliich  is  directed  towards  the  fcctus  and  li(|Uor  amnii, 
has  a  smooth  and  glistening  aspect,  being  covered  liy  the  shining 
anmiotic  membrane  ;  to  this  side  of  the  placenta  the  cord  is  attached 
near  to  but  usually  not  exactly  at  its  centre,  and  under  the  amnion 
the  funic  vessels  can  be  seen  ramifying  in  all  directions.  The  other 
side  of  the  placenta  (maternal  aspect)  has  a  very  different  appear- 
ance :  it  has  a  dark  red  colour,  is  very  irregular  on  the  surface ;  and 
here  and  there  there  are  grooves  or  sulci  which  correspond  to  the 
decidual  septa  to  which  reference  has  been  made,  and  which  sub- 
divide this  side  of  the  organ  into  lobules  or  cotyledons  as  they  are 
sometimes  called.  These  cotyledons,  it  must  be  remembered,  are 
not  primary  but  secondary  formations  in  the  case  of  the  human 
placenta.  At  its  margin  the  placenta  passes  insensil)ly  into  the 
memliranes,  chorion,  and  amnion,  which  meet  together  at  its  margin 
and  form  the  rest  of  the  bag  of  membranes  which  contains  the  fcctus 
and  the  li(pior  anmii.  Near  the  periphery,  but  in  the  substance  of 
the  organ,  is  a  more  or  less  circular  vein,  which  is  connected  with  the 
maternal  blood  supply  of  the  i:)lacenta.  Before  the  l.iirth  of  the 
infant  the  whole  placental  mass  is  attached  usually  to  the  anterior 
wall  of  the  uterus ;  and  the  maternal  aspect  of  the  placenta  after 
birth  represents  the  part  which  has  separated  therefrom  and  still 
carries  on  it  the  torn  through  decidual  tissue.  Sometimes  it  is 
situated  on  the  posterior  or  lateral  wall,  rarely  on  the  fundus,  and 
still  more  rarely  on  the  lower  jjart  of  the  cavity  of  the  uterus. 

The  blood  supply  of  the  placenta  is  a  double  one — fcctal  and 
maternal.  The  fcetal  vessels  consist  of  the  two  umbilical  arteries  and 
the  single  umbilical  vein  which  enter  it  at  the  insertion  of  the  cord  ; 
they  break  up  in  its  substance  and  pass  deeply  till  their  ultimate 
ramifications  and  twigs,  arterial  and  venous,  are  found  in  the  villi 
which  hang  in  the  intervillous  spaces.  The  maternal  vessels  are 
branches  of  the  uterine  arteries  and  veins  which  have  grown  into  the 
decidua  serotina,  and  as  it  became  changed  into  the  maternal  part  of 
the  placenta  have  enormously  enlarged  and  extended.  The  arteries, 
which  have  been  termed  on  account  of  their  sinuous  character  the 
"  curling  arteries,"  open  into  the  intervillous  spaces ;  the  veins  arise 
also  from  these  spaces,  which  indeed  connnunicate  not  only  with 
the  veins  of  the  muscular  coat  of  the  wall  of  the  utei-us  but  also  with 
the  circular  vein  of  the  placenta  (coronary  sinus,  sinus  of  Meckel). 
It  is  still  a  matter  of  dispute  and  discussion  whetlier  the  intervillous 
spaces  are  lined  with  maternal  or  fcetal  tissue.  According  to  one 
view,  the  spaces  are  really  gigantic  maternal  capillaries  lined  with 
endothelium,  into  which  the  fcetal  chorionic  villi  project  and  receive 
a  covering  of  endothelium  which  lies  upon  the  epithelium  of  the  villi 
themselves ;  according  to  the  other  view,  the  spaces  are  formed  in  a 
tissue  arising  from  a  great  jiroliferation  of  the  fcetal  epithelium 
covering  the  villi,  in  these  spaces  the  maternal  Ijlood  circulates,  for 
they  connnunicate  freely  with  both  the  maternal  arteries  and  veins, 
into  them  the  villi  hang  covered   by  the  chorionic  epithelium,  and 


124  AXTKNATAI,    I'A  THOLOGY   AND    HYC.IKNK 

they  are  in  great  ymi  liiicil  iK.t  liy  the  luatenial  vascular  endn- 
theiium  but  by  the  fa'tal  epitlieliuni.  If  the  former  view  be 
accepted,  there  lie  between  the  fn-tal  and  the  maternal  blood  (1)  tin- 
endothelium  of  the  fo-tal  vessels,  (2)  the  chorionic  epitlielial  cover- 
ing of  the  villi,  and  {'■'>)  the  maternal  vascular  endntlidium  <if  tlic 
intervillous  space;  if  the  latter  lie  the  correct  view,  there  lie  between 
the  two  liloods  only  (1)  the  endothelium  of  the  fa>tal  vessels  and 
(2)  the  epithelial  covering  of  the  villi.  According  to  the  researches 
of  Duval,  there  is  in  the  placenta  of  the  Rodents  still  less  separating- 
tissue  between  the  maternal  and  the  fcetal  blood,  for  in  it  the  villi 
hang  without  epithelial  covering  into  the  maternal  blood  in  i\u- 
intervillous  space:  while  in  the  iilacenta  of  the  Ungulata  (mare  and 
sow)  there  are  three  separating  layers  of  tissue,  fcetal  entlothehum  of 
vessels,  fcetal  epithelium  of  villi,  and  maternal  lining  of  intervillous 
space.  If  the  second  view  of  the  human  placenta  be  accepted,  il 
follows  that  the  organ  in  the  human  subject  lies  intermediate  be- 
tween that  of  the  Ungulata  and  that  of  the  Kodeutia  in  resjiect  to 
the  amount  of  tissue  which  separates  the  maternal  and  ftetal  blooil. 

Under  the  microscope,  the  villi  of  the  full-time  jilacenta  are  seen 
to  be  covered  by  a  layer  of  plasmodium  or  protoplasm  in  which  nuclei 
are  embedded  at  irregular  distances  from  each  other;  this  layer  is 
the  syncytium.  It  is  the  fcetal  epithelial  covering  to  which  reference 
has  been  made  above.  In  the  placenta  of  early  intrauterine  life 
there  is  a  second  layer  of  large  nucleated  cells  with  distinct  walls 
lying  below  the  syncytium  of  the  villi ;  this  has  been  called 
Langhans'  layer;  and  it  is  also  in  all  probaliility  foetal  in  origin. 
Langhaus'  layer  disappears  at  an  early  stage  in  the  life-history  of 
the  placenta.  The  syncytium  is  at  first  very  active,  and  from  it 
spring  numerous  buds  of  various  shapes  and  sizes  (jiroliferation- 
islancls) ;  in  it  also  are  to  be  seen  clear  or  hyaline  droplets  which 
may  become  separated  from  it  and  float  free  in  the  maternal  l)lood, 
ancl  about  the  physiological  significance  of  which  there  has  been  much 
discussion  {vide  Chap.  X.).  Under  the  epithelium  of  the  vilU  is  a  very 
delicate  connective  tissue  stroma ;  so  delicate  is  this  stroma  in  the 
terminal  villi,  that  the  eai)illaries  may  lie  said  to  lie  immediately 
iinder  the  epithelium,  and  as  the  capillaries  have  walls  consisting  of 
little  more  than  a  single  layer  of  endothelium,  it  follows  that  only  a 
layer  of  endothelium  and  one  of  epithelium  intervene  between  the 
blood  in  the  fcetal  capillaries  and  that  of  the  mother  in  the  inter- 
villous spaces.  During  the  three  last  months  of  pregnancy  the 
vessels  in  the  villi,  more  especially  of  the  marginal  part  of  the 
jDlacenta,  begin  to  show  obliterative  changes;  there  is  thickening  of 
the  intima  and  also  of  the  adventitia  of  the  terminal  and  medium- 
sized  arterioles,  and  in  them  the  circulation  therefore  slows  and 
ultimately  stops,  while  the  veins  and  capillaries  are  unatl'ected  till 
the  changes  in  the  arterioles  are  completed.  In  this  way  the  blood 
supply  to  certain  groups  of  villi  is  diminished,  and  the  syncytium 
soon  shows  atrophic  changes,  often  in  patches.  Round  the  villi 
fibrinous  infarcts  form,  and  these  are  now  regarded  by  some  writers 
not  as  pathological  structures,  bvit  as  the  natural  results  of  the  fact 


THE   MEMBRANES  125 

tliat  the  placenta  lias  learhed  the  term  of  its  active  existence 
and  is  senile.  In  the  maternal  part  of  the  placenta,  senile  changes 
also  occur  of  the  nature  of  thrombosis  in  the  sinuses,  and  are  associ- 
ated with  the  appearance  of  "  giant  cells,"  which  may  originate  the 
thrombotic  conditions.  In  this  manner,  as  has  been  pointed  out  in 
Chapter  lY.,  ji.  M9,  preparation  is  being  matle  for  the  physiological 
readjustment  uf  fiuietions  which  takes  place  at  birth. 

The  Membranes. 

The  umbilical  cord  and  placenta  are  organs  of  the  fcetus;  they 
are'  functional    necessities    of   fu'tal   life.     On   the   otlier  hand,   the 
amnion  in  its  whole  extent,  and  the  ch(jrion  and  decidual  membranes 
outside  the  placental  area,  are  structures  whose  activities  are  largely 
past ;  they  are  carried  on  by  means  of  the  placenta  into  the  foetal 
period  of  antenatal  existence,  but  their  imiiortant  part  was  played 
before  the  fo?tal  period  began ;  they  constitute  the  "  membranes  "  of 
the  full-term  laliour.      The  amnion  is   the  inner  of  the  two  fcctal 
membranes,  and  forms  a  sac  containing  the  fa?tus,  cord,  and  liquor 
amuii.    It  covers  the  foetal  surface  of  the  placenta,  and  at  the  margin 
of  that  structure  passes  out  on  all  sides  to  rest  upon  the  chorion.     It 
consists  of  a  single  layer  of  low  columnar  epithelium  with  stomata 
here  and  there,  resting  upon  a  stratum  of  wide-meshed  young  con- 
nective tissue  with  stellate  and  spindle-shaped  cells.     The  connective 
tissue  layer  is  the  e.xternal  of  the  two  which  go  to  make   up  the 
amnion,  and  it  is  in  contact  with  the  inner  surface  of  the  chorion, 
but  is  not  firmly  adherent  to  it.     The  chorion  outside  the  jjlacenta  is 
no  longer  supplied  with  villi  in  the  fu'tal  period  of  antenatal  life ;  it 
is  the  chorion  heve  or  smooth   chorion.     Its  inner  layer  is  young 
connective  tissue  with  vessels ;  its  outer  layer  consists  of  epithelial 
cells  lying  two  or  three  deep  and  resting  immediately  upon   the 
I    decidua   (maternal),   and   this    layer   is    probably   continuous    with 
I    Langhaus'   cellular   layer   over    the    placental    chorion    (or    chorion 
[    frondosum).     After  the  seventh  month  of  fietal  life  it  would  seem 
I    that  the  epithelium  of  the  chorion  heve  consists  solely  of  this  cellular 
1    layer,  there  lieing  nothing  outside  it  corresjjonding  to  the  sync^'tium 
I    or  plasmodial  tissue  of  the  villi  of  the  chorion  frondosum  or  to  its 
j   modification,  the  canalised  tibrin. 

I  The  decidual  memljranes  outside  the  placental  area  consist  of  the 

j  fused  reilexa  and  vera  of  early  intra-uterine  existence ;  but  at  the 
i  full  term  of  pregnancy  tliey  are  little  more  than  shadows  of  tlieir 
j  former  selves,  in  fact,  it  is  doulitful  if  any  recognisable  trace  of  the 
I  retiexa  exists.  Through  the  disappearance  of  the  retiexa  tlie  epithel- 
I  ium  of  the  chorion  heve  comes  into  contact  with  the  decidua  vera. 
1  Part  of  the  vera  comes  awaj'  with  the  foetal  membrane  at  the  time 
I  of  delivery,  and  part  (containing  most  of  the  glands)  remains  to  line 
j  the  cavity  of  the  empty  uterus  and  form  the  new  mucous  membrane 
(post-partum  regeneration). 

The  liquor  amnii  will    be  descrilied  more  appropriately  in    the 
j  succeeding  chapters  (Foetal  Physiology). 


CHAPTER  IX 

Physiology  of  the  Fietus  :  General  Statements;  Sources  of  Information;  Futal 
Circulation,  Extra-corporeal  or  Placental,  Intra-corporeal  with  MainCurrL-nt 
and  Secondary  Circulations  ;  Cardiac  Activity,  Peculiarities  ;  Pulse;  PjIu"! 
in  the  Fcutus,  Characters  ;  Respiration  in  the  Fcctus. 

I  HAVE  already  indicated  some  of  the  outstanding  features  of  the 
physiology  of  foetal  life,  and  have  referred  to  the  lack  of  well-estaK- 
lished  facts  in  connection  therewith;  but  it  is  necessary — at  least  '^n 
it  seems  to  me — to  attempt  a  fuller  exposition  of  the  details  of  fo-tal 
physiology,  and  at  the  same  time  still  further  to  emphasise  the 
lamentable  defects  in  our  knowledge  of  this  department  of  binlnuiial 
study.  In  attempting  to  do  the  one,  I  shall  doubtless  succeed  in 
accomplishing  the  other.  The  value  of  an  accurate  acquaintance 
with  the  facts  of  fretal  physiology  in  arriving  at  sound  cunclusinns 
with  regard  to  foetal  pathology  and  antenatal  hygiene,  is  incalculable: 
but  if  it  is  at  pre.seut  unattainable,  it  is  far  better  for  the  investigaldr 
of  this  subject  to  know  it,  for  nothing  is  more  dangerous  and  in  tiie 
long  run  more  disastrous  than  to  draw  deductions  from  data  which 
are  uncertain  and  inexact.  Let  us  then  consider  carefully  this  question 
of  Ftctal  Piiysiology. 

For  all  that  was  known  of  the  physiology  of  the  foetus  before  the 
year  1885,  we  may  turn  with  some  confidence  to  the  pages  of  Wilhelm 
Preyer's  work  —  Spccielle  rhysiolo[iic  dcs  Emhryo:  Untersnchungen 
neber  die  Lehenserscheinungen  vor  der  Gehirt — but  since  that  book  was 
published  an  immense  mass  of  observations  has  been  accumulated 
and  is  in  great  need  of  sifting.  There  is  scarcely  one  of  the  scientific 
medical  jmirnals  of  France,  Italy,  and  Germany  which  does  not  often 
add  directly  or  indirectly  to  the  number  of  articles  dealing  with  one 
or  other  of  the  aspects  of  the  physiology  of  antenatal  life,  and  the 
extensive  bibliographical  list  of  552  references  given  in  1885  by 
Preyer  might  now  be  more  than  doubled  in  length.  Thei'e  has  lieen 
no  lack  of  writing,  then,  upon  this  subject ;  but  it  may  be  confidently 
predicted  that  there  will  be  much  mcu'e  ere  the  theme  is  exhausted, 
and  the  functions  of  intra-uterine  life  investigated  and  ascertained 
with  any  degree  of  completeness  and  accuracy. 

Our  knowledge  of  tlie  facts  of  ftetal  physiology  rests  upon  obser- 
vations— (1)  upon  the  full-time  ftctus  during  labour  and  immediately 
after  liirth;  (2)  upon  prematurely  expelled  but  viable  foetuses;  (.''>)  upon 
immature  and  non-viable  f(etuses  in  abortion-sacs;  (4)  upon  ftetuses 
of  the  lower  animals,  under  {a)  normal  and  (h)  abnormal  conditions; 


f(etyvl  physiology  127 

and  (5)  upon  infants  affected  with  pathological  states  developed  in 
utero,  in  so  far  as  their  pathology  may  throw  light  upon  tiieir 
physiology.  Further,  something  is  to  he  learned  from  the  nioditica- 
tions  in  the  physiology  of  the  mother  which  occur  during  pregnancy, 
and  which  are  undoubtedly  associated  more  or  less  nearly  with  the 
changes  going  on  in  the  fcetus ;  some  information  also  is  obtainable 
from  a  careful  clinical  examination  of  the  contents  of  the  maternal 
uterus  (viz.  the  foetus)  during  gestation.  We  must,  further,  be 
ready  to  apply  to  the  study  of  fcetal  physiology  all  the  discoveries 
and  advances  made  in  connection  with  the  physiology  of  the  adult. 
AVith  all  these  means  of  acquiring  knowledge  at  our  command,  it 
might  be  expected  that  much  would  now  be  known  of  the  functions 
of  iutra-uterine  life ;  Ijut  the  other  side  of  the  question  must  Ije 
remembered — the  impossibility  of  studying,  of  seeing  even  the  fcetus 
during  its  actual  life  in  the  uterus,  the  absence  of  exact  information 
regarding  the  modifications  of  maternal  physiology  during  gestation, 
and  the  still  obscure  and  unsolved  proljlems  of  the  physiology  of  the 
adult.  When,  after  much  patience  and  great  care  and  research,  one 
problem  of  fcetal  physiology  has  been  in  some  degree  cleared  up,  the 
first  result  has  visually  been  to  bring  forward  two  or  three  subsidiary 
but  equally  difficult  problems  for  solution.  And  so,  as  Preyer  wrote 
almost  with  a  ring  of  despair  in  his  words,  "  hier  reiht  die  Physiologic 
des  Embryo  Prolilem  an  Problem."  Let  us  consider,  first,  the  least 
difficult  problem,  that  of  the  fcetal  circulation. 

The  FcEtal  Circulation. 

During  practically  the  wliole  of  the  foetal  period  of  antenatal  life 
the  circulation  of  the  blood  is  the  same.  From  the  third  to  the 
tenth  month  the  circulation  is  known  as  placental,  and  during  the 
intervening  months  it  undergoes  no  marked  modifications.  During 
the  neo-foetal  period,  it  is  true,  the  circulation  is  that  of  the  chorion ; 
but  by  the  end  of  it  there  has  been  a  specialisation  of  the  circulatory 
function,  and  the  blood,  instead  of  being  sent  to  villi  over  a  wide 
expanse  of  chorionic  surface,  is  now  directed  solely  to  those  found 
over  one  part  of  it,  that,  namely,  which  is  in  contact  with  the  deciclua 
serotina,  the  site  of  the  de^'cloping  placenta.  From  the  end  of  the 
neo-fcetal  period  onwards  to  the  moment  of  birth,  there  is  the 
circulation  of  the  placenta  (Fig.  24). 

The  essential  peculiarity  of  the  placental  circulation  is  the  sending 
of  the  foetal  blood  out  of  the  foetal  body  to  a  specially  prepared  and 
extra-corporeal  organ  (the  placenta)  for  purposes  of  oxygenation  and 
other  less  understood  chemical  changes.  This  entails  simply  the 
presence  of  an  efferent  vessel  (or  vessels)  to  carry  the  blood  to  the 
extra-corporeal  organ  and  of  an  afferent  vessel  to  bring  it  back  again. 
We  may  roughly  compare  it  to  a  coal-pit  connected  with  a  railway 
system :  to  the  pit  there  runs  a  line  of  rails  along  which  trucks 
carrying  cinders  and  rulibish  pass,  and  along  another  line  come  back 
again  the  trucks  filled  with  coal.  But  the  presence  of  this  accessory 
extra-corporeal  system  of  vessels  entails  some  slight  modifications  of 


128 


ANTKNATAI.    I*A THOLCKIY    AM)    HYdlKNK 


the  circiilatiiiii  inside  liie  fci'tal  Imdy,  fur  the  bloml  coming  fmni  the 
placenta  has  to  he  distributed  to  the  various  parts  of  the  body  in 
such  a  way  that  all  shall  share  in  it  but,  some  to  a  greater  extent 
than  others.  To  continue  the  comiJurison  which  has  been  instituted, 
the  coal  from  the  coal-pit  bus  not  only  to  be  sent  all  over  tlie  railway 


Scheme  of  I'd-tal  eireulation  (after  Preyci' 


system,  but  it  has  to  be  sent  in  special  amount  aud  of  a  special 
quality  to  the  parts  where  the  traffic  is  most  and  the  speed  of  the 
trains  greatest ;  in  order  to  carry  out  this  object,  special  lines  have 
to  be  laid  and  special  depots  built.  It  will  be  convenient  to  consider 
first  the  extra-corporeal  part  of  the  fwtal  circulation,  and  second  the 
intra-corporeal. 


FCETAL   CIKCULATIOX  129 

The  venous  blood  is  carried  from  the  f(etus  to  the  i)lacenta  by 
the  two  umbilical  arteries,  each  of  which  arises  fnnii  the  internal 
iliac  artery  of  the  same  side.  In  the  intra-abdominal  part  of  their 
course  they  are  known  as  hypogastric  arteries,  and  in  the  extra- 
abdominal  or  funic  part  as  umbilical  arteries.  Through  tliem 
impure  fcetal  l)lood  is  transmitted  to  their  ultimate  ramifications  in 
the  capillaries  of  the  villi,  where  it  may  be  said  to  be  brought,  if  not 
into  touch  with,  at  any  rate  almost  within  sight  of,  the  maternal  blood 
in  the  intervillous  spaces.  Having  undergone  arterialisation  and 
other  chemical  and  bio-chemical  changes,  the  blood  is  returned  by 
the  ultimate  branches  of  the  umbilical  vein  to  the  vein  itself,  and 
thence  through  the  umbilical  cord  to  the  abdomen  of  the  fietus.  In 
this  way  venous  foetal  blood  passes  to  the  placenta  by  means  of  two 
arteries,  and  arterial  blood  returns  from  the  placenta  by  means  of 
one  vein.  Why  there  should  be  two  laterally  originating  arteries 
and  one  mesially  situated  vein  to  carry  out  the  transit  of  the  blood, 
is  not  clear ;  but  fcetuses  in  which  there  is  only  one  artery  are 
generally  malformed  in  various  ways,  and  those  in  which  the  single 
artery  is  mesial  in  position,  and  arises  directly  from  the  abdominal 
aorta,  are  nearly  always  malformed  in  one  special  way,  namely,  show 
fusion  of  the  lower  limbs  or  sympodia  (102).  In  the  extra-corporeal 
part  of  the  ftetal  circulation,  the  venous  and  the  arterialised  bloods 
are  kept  separate;  the  blood  in  the  arteries  is  venous,  that  in  the 
vein  is  arterial. 

The  course  of  the  intra-corporeal  circulation  of  the  foetus  is  much 
more  complicated  than  that  of  the  extra-corporeal.  It  will  be  con- 
venient to  divide  it,  for  purposes  of  description,  into  a  main  current 
which  passes  from  umbilical  vein  to  umbilical  arteries,  and  into  four 
secondary  currents,  which  may  be  called  hepatic,  pulmonary,  gastro- 
intestinal, and  inferior  appendicular,  or  simply  A,  B,  C,  and  D. 

The  main  current  of  arterialised  blood  coming  from  the  placenta 

passes  in  the  umliilical  vein  to  the  liver  ;  here  the  first  secondary 

current  is  given  off,  that,  namely,  which  passes  to  the  liver  (hepatic 

or  secondary  circulation  A),  being  joined  by  the  blood  retiu-niug  in 

the  portal  vein  from  secondary  circulation  C  (gastro-intestinal) ;  the 

main  current,  however,  passes  on  directly  through  the  special  vessel, 

:  the  ductus  venosus  Arantii,  to  join  the  venous  blood  in  the  inferior 

I  vena  cava  which  is  returning  from  secondary  circulation  D  (inferior 

I  appendicular),  and  to  be  joined  by  the  return  How  from  secondary 

circulation  A  (hepatic).     The  main  current,  which   now  consists  of 

,  the  pure  blood  from  the  placenta  joined  by  the  impure  blood  from 

I  secondary  circulations  A,  C,  and  D  (hepatic,  intestinal,  and  inferior 

I  appendicular),  pours  through  the  opening  of  the  inferior  vena  cava 

1  into  the  right  auricle  of  the  heart,  and  is  almost  immediately  directed 

1  onwards  by  the   mechanism   of   the  Eustachian  valve   through  the 

;  foramen  ovale  into  the  left  auricle.     A  quantity  of  blood,  which  is 

i  small  at  the  beginning  of  foetal  life,  but  increases  as  the  full  term 

j  is  approached,  does  not  follow  this  course,  but  remains  in  the  right 

I  auricle  to  join  the  main  current  again  and  pass  into  the  right  ven- 

'  tricle,  of  which  more  anon.     The  main  current  has  now  reached  the 


130  ANTKXA'I'AI.    I'A'I'HOI.OflY    AND    IIYCIKNK 

left  auricle  (jf  tiie  heiul,  riiaii  whirli  it,  is  jjiii])elleil  1  >}•  syslole  throiiifh 
the  mitral  valve  into  the  left  veiitiiele,  hut  ))rior  to  this  it  has  heen 
joine<l  hy  the  hlood  returning  from  secondary  circulation  B  (pul- 
mf)nary).  The  mass  of  hlood  in  .the  left  ventricle,  consisting  of  tin- 
main  current  with  the  return  hlood  from  the  four  secondary  currents, 
is  now,  under  the  influence  of  ventricular  systole,  sent  on  into  tlu' 
aorta  liy  the  aortic  orifice,  and  distrihuted  hy  means  of  the  innominate 
and  the  left  carotid  antl  suhclavian  arteries  to  the  head  anil  upper 
limbs  of  the  fcetus,  a  ])ortion,  however,  passing  on  through  the  de- 
scending aorta  to  the  rest  of  the  body.  From  the  head  and  upper 
limbs  the  main  current  is  brought  back  to  the  heart  in  the  vena  cava 
superior,  and  enters  the  right  auricle,  where  it  is  joined  hy  the  blood 
which  did  not  pass  through  the  foramen  ovale,  and  they  Ijoth  jiass 
by  the  tricuspid  orifice  into  the  right  ventricle.  From  the  right 
ventricle  at  the  time  of  systolic  contraction,  the  current  passes  into 
the  first  part  of  the  pulmonary  artery,  and  immediately  gives  offjiart 
of  its  circulating  blood  to  secondary  circulation  B  (pulmonary)  by 
means  of  the  right  and  left  pulmonary  arteries ;  but  the  chief  ]iart 
flows  onwards  directly  through  the  ductus  arteriosus  into  the  aiirta, 
where  it  is  joined  by  some  of  the  blood  which  had  entered  the  aorta 
from  the  left  ventricle.  The  main  current,  having  l)een  thus  twice 
through  the  heart,  passes  first  liy  the  thoracic  and  then  by  the 
abdominal  aorta  to  the  lower  part  of  the  trunk ;  there  part  of  it  goes 
through  the  cceliac  axis,  and  the  superior  and  inferior  mesenteric 
arteries  to  secondary  circulation  C ;  the  remainder  passes  on  into  the 
two  common  iliac  arteries,  some  of  it  (the  now  much  diminished 
main  current)  going  by  the  hypogastric  and  lunbilical  arteries  ))ack 
to  the  umbilicus,  and  so  to  the  extra-corporeal  (or  placental)  circula- 
tion, while  the  rest  is  distributed  to  the  lower  limbs  as  secondary 
circulation  D  (inferior  appendicular). 

Secondary  circulation  A  may  be  descrilied  in  a  few  words.  Part 
of  the  arterialised  lilood  from  the  placenta  in  the  timliilical  vein 
leaves  the  main  cvirrent  almost  at  once,  and  goes  liy  the  afferent 
hepatic  veins  (vente  hepatis  advehentes)  along  with  the  blood  in  the 
portal  vein  to  the  sulistance  of  the  liver ;  from  the  liver  the  Ijlood 
returns  liy  the  efferent  hepatic  veins  (vente  hepatis  revehentes)  to 
join  the  circulation  in  the  vena  cava  inferior  just  before  that  vessel 
opens  into  the  heart.  It  is  evident,  therefore,  wliy  the  name  "  hepatic  " 
has  been  given  to  this  secondary  current. 

Secondary  circulation  B  takes  its  origin  from  the  trunk  of  the 
pulmonary  artery,  while  the  main  current  passes  on  by  the  ductus 
arteriosus  to  the  descending  aorta :  it,  however,  passes  to  the  lungs, 
but  in  small  quantity,  and,  having  circulated  in  the  i)ulmonary 
capillaries,  returns  by  the  veins  in  a  no  less  venous  condition  to  the 
left  auricle.  No  aeration  of  the  blood  is  going  on  in  the  lungs  in  foetal 
life,  and  this  current  might  almost  be  dispensed  with:  Juit  at  birth 
pulmonary  respiration  begins  and  secondary  circulation  IS  suddenly 
increases  in  amount,  and  becomes  of  vital  importance  to  the  infant. 

Secondary  current  C  comes  off'  from  the  main  current  in  the 
abdomen,  and  passes  by  means  of  the  cieliac  axis  and  its  branches. 


F(1:TAI.   CIRCLLATIOX  131 

and  by  the  supeiidr  and  inferior  mesenteric  arteries  and  tlieir  branches, 
to  the  stomach,  pancreas,  intestine,  and  spleen  ;  from  these  viscera 
it  is  returned  by  the  portal  vein,  vid  secondary  circulation  A  to  the 
main  current  in  the  upper  part  of  the  vena  cava  inferior.  Like  tlie 
pulmonary  circulation,  this  secondary  current  (gastro-intestinal,  as  it 
may  be  termed)  is  of  small  importance  in  the  ftetus,  this  being 
explicable  by  the  comparatively  inactive  state  of  the  stomach  and 
intestines  in  antenatal  life. 

Secondary  circulation  J)  (inferior  appendicular)  is  that  which 
passes  by  the  external  iliac  arteries  and  the  continuations  of  the  in- 
ternal iliacs  to  the  lower  limbs  and  pelvis ;  the  return  is  by  the  veins 
of  the  lower  limbs  and  pelvis  to  the  vena  cava  inferior,  and  so  to  the 
right  auricle  and  through  the  foramen  ovale  to  the  left  auricle.  The 
blood  in  this  circulation  is  of  a  markedly  venous  type. 

It  is  evident,  therefore,  from  what  has  been  said,  that  the  iutra- 
corporeal  foetal  circulation  does  not  show  that  separation  of  venous 
from  arterial  blood  which  the  extra-corporeal  does,  and  which  is 
also  met  with  in  the  postnatal  circulation.  As  a  matter  of  fact,  it 
is  only  in  the  main  circulation,  and  in  a  very  small  part  of  it,  that 
pure  blood  is  found ;  no  foetal  organ  is  supplied  with  pure  blood 
fresh  from  the  placenta.  In  the  umbilical  vein  and  in  the  ductus 
venosus  the  blood  is  of  the  best  quality ;  but  before  it  can  reach  the 
liver  by  secondary  circulation  A,  it  has  been  joined  by  the  altered 
l)lood  of  secondary  circulation  C,  and  before  it  can  reach  the  heart 
it  has  been  joined  by  the  depreciated  Ijlood  of  three  secondary  cir- 
culations, A,  C,  and  U.  It  is  unnecessary  to  subdivide  the  blood  of 
the  fa'tus,  as  Preyer  does,  into  nine  varieties,  each  having  its  own 
degree  of  venosity ;  but  the  following  general  facts  are  worth  re- 
membering. Although  no  foetal  organ  gets  blood  direct  froiu  the 
placenta  without  admixture  with  depreciated  blood,  the  liver  is 
privileged  in  receiving  it  nearly  so,  for  its  supply  is  mixed  only  with 
the  return  current  from  the  gastro-intestinal  circulation,  which 
contains  the  results  of  the  scanty  digestive  processes  of  antenatal 
life.  The  heart  itself,  the  brain,  and  the  upper  part  of  the  body, 
receive  the  next  best  blood ;  but  in  this  instance  the  next  best 
is  much  inferior  to  the  best.  The  most  venous  blood  is  not  that 
which  returns  to  the  placenta  in  the  umbilical  arteries ;  in  fact 
that  is  placed  fourth  in  order  of  merit  by  Preyer,  who  points  out 
that  it  actually  contains  some  of  the  blood  of  the  umbilical'  vein 
which  is  unaltered,  having  passed  through  no  capillary  system.  The 
most  venous  lalood  is  that  in  the  lower  part  of  the  vena  cava  inferior 
which  is  returning  from  secondary  circulation  D ;  and  it  is  a  striking 
fact  that  some  of  it  (the  most  venous  blood)  is  sent  back  again  to 
the  part  from  which  it  has  come  (lower  limbs)  without  going  to  the 
placenta.  So  some  of  the  best  blood  goes  back  to  the  placenta  un- 
altered, while  some  of  the  most  venous  is  sent  round  the  circulation 
again  without  going  back  to  the  placenta.  These  peculiarities  of  the 
foetal  cu-culation — disabilities  almost  they  may  be  called — suggest  the 
conclusion  that  it  is  truly  a  temporary  arrangement,  so  contrived  as 
to  pass  very  easily  into  the  permanent  circulation  of  postnatal  life. 


132  ANTRNATAI,    I'A  THOLCKiV    AND    UYCilF.NK 


' 


The  transition,  then,  lielweeii  tlie  eirculation  of  the  foetus  and 
that  of  the  infant  is  acconqilislied  witli  cimijiarative  ease.  It  is 
unnecessary  in  tliis  \vork,  which  deals  ])articularly  with  antenatal 
pathology  and  physiology,  to  discuss  fully  the  changes  which  take 
place  in  the  circulation  at  birth ;  but  some  of  the  more  important 
parts  of  the  readjustment  may  be  referreil  to.  The  essential  change 
is  the  elimination  of  the  e.xtra-corporeal  or  placental  circvilation,  and 
the  introduction  into  the  main  current  of  the  secondary  circulations 
E  and  I)  (pulmonary  and  inferior  appendicular).  Through  the 
closure  of  the  foramen  ovale,  the  blood  in  the  right  side  of  the  heart 
can  only  reach  the  left  side  by  passing  through  tlie  lungs ;  so  the 
secondary  circulation  B  is  taken  into  the  main  current.  Through 
the  stoppage  of  the  flow  of  blood  through  the  umbilical  arteries,  the 
main  current  in  the  lower  part  of  the  abdominal  aorta  can  only 
return  to  the  heart  by  passing  through  the  cjipillary  system  of  the  » 
lower  limbs  and  pelvis ;  so  the  secondary  circulation  J)  is  taken  in.  : 
Further,  secondary  circulation  A  (hepatic)  unites  with  secondary  ■ 
circulation  C  (gastro-intestinal)  to  form  the  single  secondary  cLrcula-  I 
tion  which  is  known  as  the  ])ortal  system;  in  it,  therefore,  two  sets 
of  capillaries  are  met  with  (hepatic  and  intestinal)  as  indications  of 
its  original  double  character.  The  postnatal  circulation,  then,  consists 
of  a  main  current  and  a  secondary  current.  The  course  of  the  main 
current  is  as  follows:  the  l)lood  in  the  inferior  vena  cava,  as  well 
as  that  in  the  superior  vena  cava,  is  poured  into  the  right 
auricle ;  thence  it  passes  through  the  auriculo-ventricular  opening 
into  the  right  ventricle;  thence  the  current  passes  on  l)y  the  pul- 
monary artery  to  the  lungs,  and,  having  traversed  the  capillaries  of 
the  lungs,  is  sent  by  the  pulmonar}'  veins  to  the  left  auricle ;  then 
the  cii-culating  fluid  reaches  the  left  ventricle,  by  whose  systolic 
contraction  it  is  propelled  by  way  of  the  aorta  to  all  parts  of  the  body, 
returning  from  the  various  capillary  systems  by  the  superior  and 
inferior  cavte.  The  single  secondary  circulation  arises  from  the 
descending  aorta ;  its  current  passes  by  the  cceliac  axis  and  its 
branches,  by  the  superior  mesenteric  artery  and  by  its  branches,  and 
by  the  inferior  mesenteric  artery  and  its  branches,  to  the  stomach, 
pancreas,  intestine,  liver,  and  spleen ;  it  returns  from  the  capillary! 
systems  of  these  viscera  (with  the  exception  of  the  liver)  by  means 
of  the  portal  vein,  which  carries  it  to  the  liver,  where  it  circulate 
through  its  second  capillary  system ;  it  then  passes,  with  the  blood 
which  has  come  to  the  liv'er  by  the  hepatic  artery,  by  means  of  the 
hepatic  \cins  into  the  inferior  vena  cava,  and  so  rejoins  the  main 
circulation. 

There  are,  then,  many  remarkable  difterences  between  the  circula- 
tion before  and  that  after  birth ;  and  yet  the  ti'ansition  from  thf 
one  to  the  other  is  carried  out  with  a  strikingly  small  amount  o! 
structural  change,  strikingly  small  when  the  residts  are  considered 
Through  the  aspiration  of  blood  to  the  lungs  from  the  right  ventricle 
the  current  ceases  or  markedly  diminishes  in  the  ductus  arteriosus 
while  that  in  the  pulmonary  arteries  and  veins  very  greatly  increases 
a  permanent  character  is  given  to  this  change  by  the  closure  of  thi 


Fa;TAI,   CAHDIAC   A(  TION  IHS 

ductus  arteriosus.  Tlimugli  tlie  return  cif  a  large  ipuuitity  of  lilnod 
from  the  lungs  to  the  left  auricle,  the  blood  pressure  in  it  is  raised, 
while  there  is  a  fall  in  the  pressure  in  the  right  auricle  througli  a 
dhuinished  return  of  blood  from  the  ])lacenta  and  the  other  parts 
of  the  fa^al  body ;  the  result  is  an  equalisation  of  the  pressure  on 
the  two  sides  uf  the  foramen  ovale,  and  the  flow  through  it  is 
checked :  the  result  is  made  permanent  by  the  membranous  closure 
of  the  foramen.  The  physiological  transition  from  the  antenatal  to 
the  postnatal  form  of  circulation  is  no  doubt  very  rapid,  but  the 
anatomical  transition  may  not  be  fully  accomplished  for  some  days 
or  even  weeks.  Physiological  closure  of  the  ductus  and  the  foramen 
happens  first,  aud  anatonucal  obliteration  of  their  lumina  follows  later, 
along  with  the  conversion  of  the  umbilical  vein  and  ductus  venosus 
Arantii  into  the  rounil  ligament  of  the  li\-er,  and  of  the  iimliilical 
arteries  into  the  vesical  ligaments.  It  is  therefore  quite  conceivable 
that  much  ditlerence  of  medical  and  more  particularly  of  medico- 
legal opinion  should  exist  with  regard  to  the  time  after  birth  when 
obliteration  of  these  canals  is  normally  completed,  and  should  exist 
in  association  with  the  well-known  fact  that  in  most  cases  the  canals 
are  immediately  closed  in  the  physiological  sense.  Into  the  vexed 
question  of  the  modus  operandi  of  the  anatomical  obliteration  of  the 
ductus  arteriosus,  etc.,  I  do  not  propose  to  enter ;  the  theories  have 
been  many,  and  the  facts  as  usual  rather  scanty,  but  they  will  all 
be  found  well  set  forth  in  P.  Strassmann's  article  {Arch.  f.  Gynack., 
xlv.  393,  1894),  and  in  G.  Gerard's  contributions  {Joiirn.  de  Vanat. 
et  de  la  physiol,  xxxvi.  1,  323,  1900).  It  may  be  remarked  that 
Strassmann's  valvular  projection  at  the  jioint  of  entrance  of  the 
ductus  into  the  aorta,  referred  to  in  the  preceding  chapter  (p.  112), 
has  been  regarded  Ijy  H.  Scharfe  {Hcgdvs  Britr.  z.  Gcburtsh.  u. 
Gynak.,  iii.  368,  1900),  as  an  artificial  production.  In  the  manage- 
ment of  the  infant  at  birth  it  seems  reasonable,  from  what  is  known 
of  the  transition  changes  in  the  circulation,  to  allow  the  respiration  to 
be  well  established  before  placing  a  ligature  upon  the  umbilical  cord. 

Cardiac  Action  in  the  Foetus. 

The  course  of  the  circulating  blood  in  the  foetus  has  been  described; 
but  the  chief  cause  of  its  movement — the  heart's  action — has  not  yet 
been  considered.  It  is  now  that  a  commencement  is  made  with  that 
part  of  the  subject  of  fcetal  physiology  which  abounds  in  problems — 
"  problem  upon  problem."  I  now  begin  to  make  frequent  use  of  the 
words  "  probably,"  "  possibly,"  and  "  perhaps";  I  lament  the  necessity, 
but  in  the  meantime  the  necessity  is  real ;  ab(jut  all  the  physiology 
of  the  fretus,  with  perhaps  the  sole  exception  of  the  course  of  the 
circulating  blood,  these  indefinite  words  will  best  express  the  know- 
ledge which  we  possess.  Here  and  there  are  scattered  facts — in  a 
wilderness  of  theories ;  aliout  some  things  even  theories  are  absent, 
none  ha\-ing  yet  been  evolved. 

In  the  case  of  the  human  fretus,  we  can  satisfy  ourselves  by 
careful  auscultation   of   the   mother's   abdomen,  that   the   heart  is 


l:U  ANTKNATAL    i-ATlK  )I,()(iY    AM)    llYdlKNF. 

active,  for  I'ldin  the  end  n{  the  fmuth  iiionlh  of  i)iegiianey  its 
beat  can  be  heard.  But,  further,  from  the  sixth  week  of  ante- 
natal life,  tlie  cardiac  action  may  be  observed  by  means  of  tlic 
examination  of  early  abortion-sacs.  It  may  therefore  be  concluded 
that  during-  the  whole  period  of  the  fu>tal  life  (sixth  week  to  end  nl' 
tentli  montli),  the  heart  of  the  unborn  is  functionally  active.  It 
])erfeetly  fulfils  all  the  recjuirements  of  antenatal  existence;  at  tin' 
same  time  its  action  ditlers  in  certain  jiarticulars  from  that  met  with 
in  postnatal  life. 

In  the  first  place,  its  activity  is  much  less  dependent  up<in  thr 
nervous  system  in  fu?tal  than  in  ])ostnatal  life — its  action  is  more 
distinctly  automa'tic.  Tiiis  peculiarity  has  Ijeen  over  and  over  again 
demonstrated  Iiy  the  birth  of  fcetuses  without  brain  or  spinal  cmd 
(anencephalic  and  amyelic),  wlmse  heart,  beat  had  lieen  heard  befoie 
birth,  and  seen  at  birth.  Further,  F.  Nengebauer  (Ccutrllil.f.  Gynal:.. 
xxii.  1281,  1898)  has  shown  how  long  this  automatic  activity  may 
continue.  The  case  was  a  somewhat  remarkable  one  :  the  fwtus,  age 
fourteen  weeks,  was  removed,  liy  operation,  from  an  extrauterine 
gestation  sac;  in  the  process,  its  head,  arms,  a  leg,  and  the  whole  ><i 
its  spinal  cord  were  torn  away,  leaving  only  the  trunk  with  one 
lower  liml)  attached;  yet  the  heart  continued  to  beat  in  an  automatii'. 
rhythmical  fashion  for  more  tlian  three  hours ;  at  first  the  rate  was 
one  beat  every  two  seconds,  but  it  gradually  slowed  until  it  was  one 
every  five  seconds;  the  contraction  was  noted  to  be  antiperistaltic, 
beginning  with  the  ventricles  and  then  extending  to  the  auricles ; 
and  the  movement  of  the  cardiac  apex  was  upwards,  forwards,  and 
to  the  right.  In  a  somewhat  similar  case  reported  by  Wasten  ami 
referred  to  by  Neugebauer  {Cintrlhl.  f.  Gynal:.,  xxiii.  465,  1899),  tbi' 
heart  beat  for  two  and  a  quarter  hours.  In  E.  I'eiser's  observatiim 
{C'rntrlhl.  f.  Gyndk.,  xxiii.  10:jo,  1899),  the  ftetus  was  five  months 
old  ;  when  its  body  was  quite  cold  tlie  thorax  was  opened,  and  I'eiser 
was  then  startled  to'  see  "  tlie  interesting  spectacle  of  the  beating 
human  heart "  ("  das  interessante  Schauspiel  des  schlagenden  menscb- 
lichen  Herzeus").  The  auricles  contracted  liefore  the  ventricles, 
and  the  right  scarcely  preceded  the  left;  the  apex  was  raised  and 
turned  towards  the  right.  After  twenty  minutes  the  heart  was 
separated  from  the  great  vessels  and  placed  in  a  warm  saline  solution, 
where  it  continued  to  beat,  Ijut  with  less  marked  movements.  Its 
activity  continued  for  over  an  hour  altogether.  Observations  of  a 
like  kind  were  made  by  E.  C)])itz  (C'entrlbl.  f.  Gjpx'lk.,  xxiii.  6,  810, 
1899).  The  fo'tal  heart  therefore  has  a  very  consideral)le  degree  of 
automatic  activity. 

In  the  second  place,  the  ftetal  cardiac  activity  is  not  so  im- 
mediately dependent  upon  the  oxygenation  of  the  blood  as  is  the 
heart's  action  in  jiostnatal  life.  The  blood  in  tlie  f(etus,  with  the 
exception  of  that  in  secondary  circulation  A,  is  far  from  being  well 
oxygenated.  Even  in  the  infant  at  the  moment  of  birth  respiration 
may  not  be  established,  and  yet  the  heart  may  continue  visibly  to 
beat  for  some  time,  for  hours  even ;  cases  in  which  an  asphyxiated 
infant  was  resuscitated  after  the  lapse  of  hours,  will  recur  to  the 


FCETAL   CAKDIAC   ACTION  135 

iniiul  of  almost  every  obstetrician  who  has  had  a  hnig  obstetric 
experience.  I  have  met  with  a  case  in  which  cardiac  activity 
continued  for  five  hours  after  birth  without  tlie  huigs  having  come 
into  play ;  the  foetus  in  this  instance  was  the  subject  of  a  number  of 
malformations.  There  is  not,  however,  any  evidence  to  show  that 
the  foetal  heart  will  continue  to  beat  for  anything  like  this  time  in 
the  uterus  after  the  death  of  the  mother ;  as  a  matter  of  fact,  there  is 
little  chance  of  saving  the  infant  if  the  post-mortem  opening  of  the 
maternal  abdomen  and  uterus  be  delayed  longer  than  five  minutes. 
The  circumstances,  however,  differ  widely,  and  the  rapid  death  of  the 
fa?tus  after  the  death  of  the  mother  is  not  to  be  ascribed  solely  to 
defective  oxygenation  of  its  blood. 

In  the  third  place,  it  may  be  safely  concluded  that  the  events  of 
the  cardiac  cycle  are  not  so  clearly  marked  off  and  so  unalterable  in 
their  sequence  in  the  fcetus  as  in  the  child  or  adult.  For  instance, 
in  the  observation  of  Xeugebauer  already  referred  to  (loc.  cit.  siqyra), 
the  contractions  were  anti-peristaltic,  beginning  with  the  ventricles 
and  spreading  to  the  auricles.  Usually  the  auricles  contract  first, 
the  right  slightly  in  advance  of  the  left ;  then  there  is  a  short  pause ; 
then  the  ventricles  p)ass  into  systole,  the  right  being  immediately 
followed  by  the  left ;  and  then  intervenes  another  pause,  scarcely  of 
greater  duration  than  the  former.  The  pauses  are  of  nearly  equal 
length ;  and  the  whole  cycle  lasts  from  0'3  to  0'6  of  a  second,  of 
which  more  than  half  is  occupied  with  the  ventricular  systole.  The 
impulse  and  the  mo-s'ements  of  the  heart  would  seem  to  be  the  same 
as  in  postnatal  life,  if  it  be  permissible  to  draw  conclusions  from  the 
observation  of  the  organ  in  ftetuses  which  have  been  expelled  in 
abortion  sacs. 

In  the  fourth  place,  the  fcetal  heart  rate  is  much  quicker  than 
the  adult ;  but  there  is  a  gradation  from  the  one  to  the  other 
through  the  rate  in  the  infant  and  in  the  child.  In  the  early  months 
of  fojtal  existence  it  has  been  supposed  that  the  rate  is  slower  than 
in  the  later  months ;  but  the  heart  sounds  are  not  audible  in  the 
beginning  of  pregnancy,  and  therefore  the  estimation  of  the  raj^idity 
of  action  has  had  to  be  made  from  observations  on  ftetuses  after  their 
expulsion  from  the  uterus,  manifestly  a  method  not  free  from  fallacy. 
From  the  fifth  month  onwards  to  the  full  term,  it  seems  well 
estabhshed  that  the  fcetal  heart  beats  at  the  rate  of  132  per  minute, 
or  thereby,  with,  under  certain  circumstances,  a  slackening  in  rate 
down  to  100  or  less,  or  an  accelei-ation  up  to  180  or  more. 
Immediately  after  the  birth  of  the  infant  there  is,  it  is  believed,  a 
transitory  increase  in  the  cardiac  rate,  followed  by  a  slowing,  ascribed 
to  the  gradual  development  of  the  controlling  influence  of  the  vagus. 
In  the  fifth  place,  the  course  of  the  blood  through  the  heart  is 
not  the  same  in  the  foetus  as  in  the  infant,  and  the  quality  of  the 
blood  passing  through  the  various  chambers  also  differs.  In  no 
chamber  of  the  fcetal  heart  is  there  absolutely  pure  arterial  blood, 
and  that  of  the  right  auricle  is  little  belter  (or  worse)  in  this  respect 
than  that  of  the  left. 

There  are  other  details  in  which  the  action  of  the  foetal  heart 


136  ANTKN'ATAI,    I'A  TllOLOCV    AND    HY(;iKNK 

doubtless  dilll'is  from  that  of  the  circulatory  or^aii  in  postnatal  life, 
l)ut  over  tliein  and  other  e(|ually  obscure  matters  we  must  not  Iohli; 
linger.  For  instance,  it  may  very  well  be  that  variations  in  the  rale 
of  the  heart-beat  do  not  depend  ujiou  just  the  same  circumstances. 
Little  is  known  about  the  influences  which  quicken  and  those  which 
slow  the  fcctal  heart;  l)ut  (1)  activity  of  the  fu^tal  movements  is 
generally,  if  not  always,  followed  by  increased  rate  of  fa'tal  pulse ; 
(2)  increase  in  rate  of  the  maternal  pulse  is  sometimes  associated 
with  increase  and  sometimes  with  decrease  in  rate  of  the  fo'tal  ])ulse; 
(o)  the  greater  the  size  and  weight  of  the  fcutus,  the  slower,  in  a 
general  sense,  is  its  heart  beat,  but  there  is  no  constant  relation 
between  the  two ;  and  (4)  the  female  fcetus  has  a  quicker  pulse  than 
the  male,  possibly  because,  as  a  rule,  she  is  of  smaller  size  and 
weighs  less.  It  is  not  known  whether  changes  in  the  position  of  tln' 
foetus  in  utero,  eg.  from  cephalic  to  pelvic  presentation,  or  from 
cephalic  to  transverse,  alter  the  rapidity  of  the  heart's  action ;  and 
very  little  is  certain  with  regard  to  the  effect  of  medicines  or  fooil 
given  to  the  mother  upon  the  fcetal  pulse ;  and  yet  these  are  matters 
into  which  in([uiry  is  practicable  in  maternity  hospitals  if  not  in 
private  practice. 

It  is  generally  stated  and  believed  that  in  the  pains  of  labour  the 
rapidity  of  the  ftetal  heart  is  diminished — to  the  extent  of  as  much 
as  ten  beats  in  the  minute.  Various  theories  have  been  advanced  to 
explain  this  supposed  slowing  of  the  heart;  it  has  been  ascribed  to 
compression  of  the  placenta  by  the  contracting  uterus  increasing  tlie 
pressure  in  the  umbilical  arteries,  to  the  general  compression  of  the 
fcetus  by  the  uterus,  to  the  compression  of  the  f fetal  cranium  (c.//.  by 
forceps)  stimulating  the  vagi  near  tlieir  origin,  and  to  stimulation  of 
the  vagi  by  the  venous  condition  of  the  fcetal  blood  produced  by  the 
uterine  contractions.  Objections  may  be  urged  against  all  these 
theories,  and  with  regard  to  the  last,  which  is  in  some  respects  the 
most  probable,  it  has  to  be  noted  that  the  interference  with  the 
supply  of  oxygen  to  the  nerve  centres  in  a  labour  pain  nnist  be  of  a 
trifling  nature.  Indeed,  Pestalozza  {Rasaeijna  d.  $r.  mnl.,  Modena,  vi. 
405,  473,  1891)  has  calculated  how  much  oxygen  would  be  required 
by  the  fcetus  during  a  labour  pain,  and  has  found  it  to  be  so  small  as 
to  give  no  support  to  the  above  view.  There  is,  however,  no  need 
for  further  discussion  <if  this  matter,  for  it  is  admitted  that  the  super- 
vention of  a  uterine  contraction  may  not  in  some  cases  be  followed 
by  slowing,  but  by  acceleration  of  the  fcetal  heart.  In  this  relation 
Pestalozza's  cardiogram,  obtained  while  the  fcetus  was  still  in  utero, 
deserves  a  paragraph  to  itself. 

It  has  now  and  again  lieen  noted  that  the  fcetal  heart  could  not 
only  be  heard  but  be  actually  felt  tlirough  the  mother's  abdominal 
walls,  by  the  obstetrician  during  labour.  Some  seven  cases  of  this 
kind,  including  two  original  ones,  were  published  by  D.  F.  Duval 
{Johns  Hopkins  Hasp.  Bull.,  viii.  207,  1897)  four  years  ago,  in  all 
of  which,  through  the  fietal  presentation  l>eing  a  brow,  a  face,  or  an 
oceipito-posterior  one,  the  chest  of  the  infant  was  brought  into  close 
contact  with   the  anterior    uterine  wall,  and    through    it  witli  the 


Fa:TAI,   CARDIOCIUAM  137 

anterior  abdoniiiial  wall ;  in  these  cases  the  filial  lieart  was  felt  by 
the  obstetrician's  finger  and  its  rate  ascertained.  Dnval,  however, 
does  not  refer  to  the  important  case  reported  by  Pestalozza 
{loc.  cit.  si'.jira),  in  which  not  only  was  the  foetal  heart-lieat  felt 
through  the  maternal  abdominal  wall,  but  a  cardiographic  tracing 
of  it  olitained.  The  case  was  one  of  a  twin  laljour,  and  during 
the  expulsion  of  the  first  fcetus,  the  second  one,  which  was  lying 
transversely  with  its  back  to  the  mother's  back,  was  jiushed  forward 
against  the  anterior  uterine  wall  to  such  an  extent  that  its 
heart-beat  could  be  distinctly  felt  in  the  upper  part  of  the 
maternal  abdominal  wall  on  the  right  side.  The  rate  was  140  per 
minute.  With  the  Dudgeon  sphygmograph,  the  only  instrument 
available  in  the  emergency,  three  tracings  were  obtained,  two  between 
pains  and  one  during  a  contraction ;  of  the  two  taken  between  the 
pains,  one  was  during  ordinary  respiration  and  the  other  was  while 
the  patient  held  her  In'eath.  At  the  time  when  the  cardiograms 
were  taken,  the  membranes  of  the  second  infant  were  still  intact,  but 
there  was  not  much  liquor  amnii ;  the  uterine  and  abdominal  walls 
wei'e  thin,  a  circumstance  which  helped  to  make  the  observation 
possible.  The  tracings  sliowed  a  rapid  rise  of  pressure  to  the  apex 
(opening  of  semilunar  valves),  followed  not  by  a  sudden  decrease  of 
pressure,  but  by  a  continuance  of  it  ("  platform "),  and  then  by  a 
descent  to  the  base  line,  a  fact  which  may  be  interpreted  as  proving 
that  the  blood  does  not  get  very  quickly  or  easily  out  of  the 
ventricles.  It  is  noteworthy  that  in  the  cardiogram  taken  during  a 
uterine  contraction  there  was  no  slowing  of  the  rate  of  the  heart's 
action.  Pestalozza  was  able  to  add  greatly  to  the  value  of  his  unique 
tracings,  by  taking  cardiograiiis  of  a  new-born  infant  which  had  not 
respired,  but  which  was  not  yet  in  a  state  of  true  asphyxia,  of  an 
infant  in  a  condition  of  true  asphyxia  neonatorum,  and  of  an  infant 
in  whom  respiration  had  been  fully  established.  In  the  state  of 
simple  apnoea  the  cardiogram  exactly  resembled  those  obtained  from 
the  fcetus  in  utero ;  in  that  from  the  asphyxiated  infant  there  was 
slowing,  irregularity,  and  a  liroader  "  platform  "  in  the  tracing;  while 
in  that  from  the  infant  in  whom  respiration  had  been  established 
there  was  a  complete  loss  of  the  fcetal  characters  and  an  assumption 
of  the  adult  type.  Too  much  reliance  must  not,  of  course,  be  placed 
upon  the  evidence  obtained  from  so  few  observations ;  but  it  may  in 
the  meantime  be  provisionally  maintained  that  the  human  fcetus  has 
a  cardiogram  which  differs  from  that  of  the  new-born  infant  which 
has  respired,  and  that  its  characters  are  those  shown  in  Pestalozza's 
tracings. 

It  may  here  be  noted  that  it  has  been  generally  believed  that  the 
pulse  in  the  new-born  infant,  and  in  the  foetus  also  it  is  presumed, 
is  one  of  very  low  tension,  and  exhibits  no  proper  apex  or  wavelets. 
Indeed,  it  has  been  stated  that  no  apex  develops  till  the  seventh  year 
and  no  dicrotic  wavelet  till  the  tenth,  and  this  statement  I  accepted 
and  repeated  in  my  work.  An  Introduction  to  the  Diseases  of  Ivfancy 
(1.,  p.  163).  I  now  reproduce  here  two  sphygmographic  tracings  which 
my  friend  Dr.  Oliphant  Nicholson  has  recently  obtained,  one  from 


138 


ANTKNATAL    I'ATHOLOdY    AND    H V(;iF.NK 


;ui  iiifauL  five  luimites  old  (Fij^.  25)  ami  the  dIIilt  fnnu  a  child  of  six 
days  (Fig.  26),  holli  in  puil'eet  health;  il  will  he  noted  that  in  both 
there  is  relatively  high  tension,  a  well  marked  apex,  and  tidal  and 
dicrotic  wavelets.  It  may  therefore  be  conclnded  that,  with  a  delicate 
sphygmograph  and  sufficient  care  in  employing  it,  such  tracing.?  are  ob- 


tainable from  the  pulse  of  the  normal  new-born  infant.  No  sphygnio- 
graphic  tracings  have  yet  l)een  olitained  from  the  foetus  in  iitein 
(membranes  unruptured),  and  it  is  difficult  to  imagine  conditions  in 
which  they  could  lie  taken  ;  Imt  the  sphygmogram  of  an  infant  born 
lirematurely  at  the  seventh  month  shows  a  more  sloping  line  of 
ascent  to  the  apex. 

In  the  chapter  which  deals  with  antenatal  diagnosis,  a  further 
reference  will  be  made  to  the  auscultation  of  the  foetal  heart,  and 
so-called  funic  souffle. 


The  Blood  in  the  Foetus. 

Our  knowledge  of  the  characters  of  the  blood  of  the  fiptus  is  in 
great  measure  founded  ujmn  the  examination  of  full-time  infants  at 
or  soon  after  birth  :  to  a  small  extent  only  have  observations  of  the 
blood  of  prematurely  expelled  foetuses  been  utilised  in  the  research — 
a  regrettable  neglect.  Let  us  consider,  first,  the  histological  and 
chemical  characters  of  the  blood  of  the  foetus,  and  second,  its  mode 
of  formation  or  luematopoie.sis. 

The  blood  of  the  ftetus,  just  like  the  blood  of  the  adult,  is  made  up 
of  corpuscles  and  of  plasma,  and  the  corpuscular  elements  are  of  two 
kinds,  red  and  white  cells. 

During  recent  years  a  good  many  valualile  observations  have  been 
made  upon  the  red  cmpuscles  of  the  fcftal  blood,  and  I  may  cite 
specially  the  work  of  Elder  and  Hutchison  (Trans.  Edinh.  Ohst.  ,^oc., 
XX.  154,  1895),  of  Bidone  antl  Gardini  (Arch.  ital.  dc  bioL,  xxxii.  36, 


BLOOD    IX   THI':   l'(KTU.S  139 

1899),  i.f  Fernini  (Ann.  di  os/,V.,  xxi.  791,  1899),  of  iSI'iuiiLUii  {llni!., 
xxi.  851,  1899),  and  uf  Varaldo  (Arch,  di  osf.et.,  vii.  72:!,  1900). 
From  these  and  from  earlier  investigations  on  tliis  subject  it  may  l)e 
concluded  that  the  red  corpuscles  are  more  numerous  in  the  l)l(iod 
of  the  tVetus  than  in  that  of  the  adult  or  child.  ISut  there  is  ni> 
general  agreement  as  to  how  much  more  numerous  they  are,  although 
it  may  be  stated  roughly  that  the  infant  at  the  moment  of  birth  has 
from  one  half  to  a  million  more  red  corpuscles  per  c.nnn.  than  an  adult. 
It  is  worthy  of  note,  however,  that  the  difference  in  this  respect 
l)etween  the  fcetal  blood  and  that  of  the  mother  is  usually  much 
greater  than  that  lietween  the  former  and  the  blood  of  a  non-jiregnant 
adult ;  for  tlie  maternal  Ijlood  in  pregnancy  is  poor  in  red  cells,  and 
consequently  the  difference  between  the  number  of  corpuscles  in  the 
mother  and  her  foetus  may  amount  to  as  much  as  two  or  two  and  a 
half  millions  per  c.mm.  in  favour  of  the  latter.  The  number  of  red 
corpuscles  in  the  foetal  blo(3d  may  then  be  put  at  from  six  to  six  and 
a  half  millions  per  c.mm.  In  premature  fcetuses  (seven  to  nine  months) 
the  numlier  of  xanthocytes  rises  still  higher  and  is  connnonly  above 
seven  millions  per  c.mm. ;  and  Bidone  and  Gardini  {luc.  cit.)  have 
met  with  a  case,  an  eight  months  fcetus,  in  which  there  were  no  less 
than  8,240,8:!;'  per  c.mm.  As  the  number  of  red  corpuscles  in  the 
maternal  blood  is  not  greater  in  the  early  part  of  pregnancy,  it 
follows  that  the  disproportion  between  the  corpuscular  richness  is 
more  marked  for  premature  than  for  full-term  fo'tuses ;  there  is  a 
difference  of  more  than  three  millions  in  favour  of  the  fcetus  (Ferroni). 
It  is  a  remarkable  fact,  that  even  when  the  mother  is  antemic  in 
excess  of  the  ordinary  amemia  of  pregnancy,  the  red  cells  of  the 
fietal  blood,  although  diminished  in  their  absolute  amount,  are 
relatively  little  interfered  with,  so  that  in  such  cases  the  dispro- 
portion lietween  the  two  bloods  is  intensified  (Ferroni).  From  all 
these  facts  it  may  be  safely  concluded  that  ftftal  Idood  in  the  three 
last  months  of  antenatal  life  is  peculiarly  rich  in  erythrocytes,  and 
that  this  richness  is  not  directly  related  to  the  state  of  the  maternal 
blood.  What  may  be  the  significance  of  this  persistent  corpuscidar 
richness  of  the  ftetal  blood,  it  is  impossible  to  say  with  any  degree 
of  assurance,  but  it  is  noteworthy  that  in  cases  of  cyanosis  from 
congenital  cardiac  defects  it  is  maintained  long  after  birth. 

In  addition  to  the  orilinary  non-nucleated  red  corpuscles,  the 
blood  of  the  ftetus  contains  a  certain  number  of  nucleated  xantho- 
cytes (ei-ythroblasts).  They  persist  after  birth,  but  only  for  a  limited 
time  (three  days  or  so),  when  they  average  from  1  to  20  to  1  to  8  of 
the  white  corpuscles ;  but  in  pseudo-leukremic  amemia  of  children 
and  in  athyria  they  may  reappear  in  the  blood.  Some  are  mono- 
nucleated  and  others  contain  two  nuclei  (Varaldo).  In  premature 
fcetuses  they  are  more  numerous,  and  the  younger  the  fcetus,  the 
more  numerous  they  are  ;  this  at  any  rate  is  probalile,  for  it  has  not 
been  definitely  proved. 

It  may  be  added  that  in  fcetal  blood  there  are  to  be  seen  red 
corpuscles  which  stain  either  in  whole  or  in  part  with  methylene  blue 
(young  cells,  probably),  and  others  containing  granules  which  stain 


140  ANTKNATAI,    I'AIHOI.OtiY    AND    HYGIFAE 

with  Ehrlic'h's  neutral  red.  It  has  also  lieeii  stated  that  the  xantho- 
cytes  ditl'er  in  size  and  slmpe  from  those  of  adult  blood. 

The  ha-moglobin  of  the  fo'tal  lilood,  like  the  red  corpuscles,  is  in 
e.Kcess  of  that  in  the  adult,  and  greatly  in  e.xcess  of  that  in  the 
maternal  blood.  As  measured  by  Fleischl's  luenioineter,  it  averages 
about  120°  (]5idone  and  Ferroni),  but  may,  especially  in  jjremature 
foetuses,  rise  aliove  125°;  it  is  thus  aliont  fifty-two  divisions  of  the 
hfemouieter  higher  than  with  the  maternal  lilood.  Further,  as  with  the 
red  corpuscles  so  with  the  h;emoglobin,  an  aniemic  condition  of  the 
maternal  blood  does  not  affect  the  richness  of  the  fa'tal  blood  in  this 
constituent  to  an  appreciable  extent,  it  simply  exaggerates  the  dis- 
proportion already  existing.  It  does  not  appear  that  the  sex  of  the 
foetus  has  any  effect  upon  the  number  of  corpuscles  or  the  amount 
of  hicmoglobin  in  the  blood ;  and  it  has  not  been  observed  that  there 
is  any  relation  between  the  weight  of  the  fietus  and  the  characters  of 
its  blood,  an  increase  in  weight  not  being  accompanied  by  any  in- 
crease in  the  number  of  erythrocytes  or  in  the  quantity  of  haemo- 
globin (Ferroni).  It  may  be  interpolated  here  that  there  is  some 
reason  for  supposing  that  a  large  quantity  of  erythrocytes  and  <if 
haemoglobin  in  the  maternal  blood  in  pregnancy  is  likely  to  be  more 
often  associated  with  male  than  with  female  foetuses :  but  there  is 
no  evidence  that  the  characters  of  the  maternal  blood  in  these  re- 
spects have  any  relation  to  the  weight  and  length  of  the  ftctus. 
It  is  believed  that  foetal  oxy-luemoglobin  is  more  difficult  to  reduce 
than  maternal,  possibly  because  it  has  a  difi'erent  molecular  constitu- 
tion. G.  Zanier  {Arch.  ital.  de  hioL,  xxv.  58,  1896)  has  made 
observations  on  the  resistance  of  tlie  fa>tal  as  compared  with  the 
maternal  blood  in  the  cow,  and  has  found  that  it  is  distinctly  greater 
in  the  former :  but  there  is  need  for  further  research  upon  this  as 
upon  so  many  other  points  in  the  physiology  of  the  fwtus.  Some 
attempts  have  been  made  to  ascertain  the  respiratory  capacity  of  the 
foetal  blood  at  different  ages,  and  Nicloux  (Compt.-rend.  Soc.  de  hiol.  de 
Paris,  liii..  p.  120,  1901)  has  found  that  from  six  months  to  the 
full  term  the  capacity  is  practically  the  same ;  he  estimated  that  the 
hiemoglobin  of  the  blood  of  a  foetus  of  six  and  a  half  months, 
weighing  1320  grms.,  was  capable  of  fixing  as  much  oxygen  as  that 
of  a  fujtus  at  term  weighing  37;'>0  grms.  In  this  important  and 
fundamental  property  of  tlie  firtal  blood,  therefore,  there  is  little 
variation  in  the  later  months  of  antenatal  life. 

With  regard,  now,  to  the  other  corpuscular  element  in  the  fo-tal 
blood,  the  white  corpuscles,  it  has  to  be  noted  that  they  are  also 
increased  in  uumlter  as  compared  with  the  adult  state.  According 
to  Elder  and  Hutchison  {loc.  cit.),  the  leucocytes  nundter  nearly 
18,000  per  c.nnu.,  or  twice  as  many  as  are  met  with  in  adult  blood: 
the  excess  of  the  white  is  relatively  nmch  greater  than  the  excess  of 
the  red,  there  being  in  the  infant  at  birth  1  white  to  298  red,  and 
in  the  adult  1  white  to  500  red.  They  are  also  increased  in  the 
blood  of  the  pregnant  woman,  l)ut  not  to  anything  like  the  same  extent. 
Tiiere  is,  therefore,  marked  ftetal  leucocytosis.  The  white  corpuscles 
are    of   various    kinds,    ]iiilymoriilionuclear    leucocytes,    lymphocytes 


BLOOD    IX   THK    F(1:TUS  141 

(small  inono-iiuclear),  large  mouu-nuclears  or  transitional  forms,  and 
eosino])hiles ;  there  are  also  cells  with  acidophilic  and  hasophilic 
granules,  although  Elder  and  Hutchison  saw  none  of  the  latter.  Max 
Carstanjen  (Jahrh.  f.  Kindfrldlc,  ?)  F.,  ii.  1215,  1900)  and  others 
liave  attempted  to  estimate  the  relative  proportion  of  the  different 
forms  of  white  corpuscles  in  the  fu^tus ;  and  it  would  seem  that  the 
polymorphonuclears  are  more  numerous  than  the  lymphocytes,  but 
that  within  a  few  days  after  birth  they  are  practically  equal,  and 
that  later  still  there  is  lymphocytosis;  the  transitional  forms  are 
perhaps  more  numerous  than  in  the  adult,  but  the  eosinophiles  are 
not  relatively  increased. 

Such  are  some  of  the  characters  of  the  blood  of  the  ftetus  which 
\m\&  been  established  with  a  certain  degree  of  probability  ;  some  other 
characters  not  so  fully  determined  may  be  referred  to.  With  regard,. 
for  instance,  to  urea,  Cavazzani  and  Levi  {Ann.  di  ostet.,  xvi.  456, 
1894)  have  found  that  apparently  there  is  no  correspondence 
between  the  quantity  of  this  substance  in  the  maternal  and  in  the 
fcetal  blood ;  further,  the  amount  does  not  seem  to  be  related  to  the 
development  or  sex  of  the  foetus,  or  to  the  age  of  the  mother,  but 
there  is  more  urea  in  the  foetal  blood,  if  the  expulsive  stage  of  labour 
has  been  short;  the  average  quantity  is  0'215  per  1000.  Cavazzani, 
also,  states  that  there  is  more  glucose  in  the  maternal  than  in  the 
foetal  blood,  a  fact  wliich  would  seem  to  show  that  even  eminently 
soluble  substances  do  not  pass  through  the  placenta  from  mother  ta 
foetus  or  from  fojtus  to  luother  by  the  simple  laws  of  osmosis.  It  may 
be  that  the  placenta  has  a  power  of  selection ;  in  fact  this  is  almost 
certain.  Nucleon,  or  phospho-carnic  acid,  is  a  substance  which  has- 
been  lately  shown  by  Sfameni  to  exist  in  the  fcetal  blood  {Ann.  di 
ostet.,  xxii.  1009,  1900)  to  the  amount  of  0'2106  per  cent.;  its 
quantity  does  not  seem  to  be  influenced  by  the  sex  of  the  foetus,  or 
by  conditions  of  the  mother,  but  the  greater  the  weight  of  the  fcetus- 
the  smaller  apparently  is  the  quantity  of  nucleon  in  the  blood. 
There  is  twice  as  much  in  the  blood  as  in  the  placenta.  The  density 
of  the  fcetal  blood  (1060)  is  greater  than  of  the  adult,  notwithstand- 
ing the  fact  that  the  former  fluid  contains  slightly  more  water  than 
the  latter.  The  foetal  blood,  also,  is  said  to  contain  less  water  than 
the  foetal  tissues ;  if  this  be  true,  it  would  seem  to  prove  that  the 
water  of  the  tissues  must  come  from  some  other  source  than  the 
blood,  possibly  from  the  liquor  amnii.  As  compared  with  adult 
blood,  that  of  the  infant  at  birth  contains  rather  less  mineral  matters. 
The  blood  of  the  male  fcetus  contains  more  organic  matters,  but  less 
water  and  less  soluble  and  insolulale  salts,  than  that  of  the  feiuale. 
Sfameni  {Ann.  di  ostet.,  xxi.  851,  1899),  gives  the  average  composi- 
tion of  foetal  blood  as  follows  : — 

Water         .         .  .         .  78 '52  per  cent. 

Solids 21-47       „ 

Organic  .....  20'72       ,, 

Inorganic         ....  0'74       „ 

Soluble  salts         ...  0-62       „ 

Insoluble  salts      .         .         .  0'12       ,, 


142  AN'II'.NAIAI,    I'AlHOLCXiV   AND   HYGIENE 

Fiiiin  the  researches  of  Hngounenq  (Jonrn.  dc  physiol.  ct  de  path,  tj^ti., 
i.  703,  1899)  it  would  seem  that  from  50  to  GO  per  cent,  of  the  total 
amount  of  iron  in  tiie  fcptal  body  is  in  the  blood. 

Manifestly  there  is  much  to  be  done  before  the  characters  and 
composition  of  the  fictal  blood  can  be  stated  with  any  degree  of 
accuracy,  and  much  more  l)efore  the  meaning  of  these  characters 
and  the  bearing  of  the  composition  can  lie  satisfactorily  deteriinned. 
At  the  same  time,  as  has  been  shown,  a  beginning  has  Iieen  maile.  An- 
other subject  around  which  it  must  lie  confessed  that  much  obscurity 
exists,  is  the  mode  of  origin  of  the  corpuscular  elements  of  the  blo<id 
in  the  ftctus.  It  would  seem,  however,  that  from  the  time  of  its 
formation  until  the  full  term,  the  fo'tal  liver  j^lays  a  part  in  tiii' 
formation  of  both  the  red  and  the  white  corpuscles;  in  this  organ 
the  blood  pressure  is  low,  the  cun-ent  slow,  and  nourishment  abund- 
ant, conditions  which  favour  its  luematopoietic  functions.  0.  van 
der  Stricht  {Arch,  de  hioloyic,  xii.  199,  1892)  has  made  a  series  of 
elaborate  investigations  on  the  formation  of  both  erythroblasts  and 
leucoblasts  in  the  mammalian  foetus,  and  has  found  in  the  liver 
special  haematopoietic  capillaries  in  which  ai-e  formed  the  white 
and  red  corpuscles.  The  white  are  not  related  in  any  way  to  the  red  ; 
they  have  distinctive  characters  at  all  stages  in  their  tlevelopment. 
The  red  corpuscles  originate  from  the  erythroblasts  by  the  expulsion 
or  disappearance  of  the  nucleus.  In  the  spleen,  also,  erythroblasts 
and  leucoblasts  arise,  the  former  in  the  splenic  pulp,  and  the  latter 
in  the  Malpighian  corpuscles.  Possibly  there  is  a  production  of 
blood  corpuscles  in  other  tei'ritories  in  the  foetal  body  in  which  the 
blood  pressure  is  low.  J.  Beard  (Anaf.  Ajiz.,  xviii.,  pp.  550,  561, 
1900)  is  strongly  of  the  belief  that  the  thymus  gland  in  its  epithelial 
portion  is  the  first  source  of  leucocytes,  that  it  is  in  fact  the  parent 
source  of  all  the  lymphoid  structures  in  the  body;  according  to  (!. 
L.  Gulland,  the  white  corpuscles  already  existing  in  the  blood  (ori- 
ginal source  luicertain)  are  caught  in  the  reticular  tissue  of  the  ftctal 
lymphatic  glands,  and  then  begin  to  multiply  there  (Journ.  of  Path, 
and  Baderiol.,  ii.  447,  1894).  It  is  an  interesting  fact  that  Varaldo 
{loc.  cit.)  has  found  more  leucocytes  in  the  umbilical  vein  than  in 
the  umbilical  arteries — there  were  on  an  average  4000  more  leuco- 
cytes per  c.mm.  in  the  vein.  This  excess  of  leucocytes  in  the 
matrifugal  as  compared  with  the  matripetal  blood  stream  is  ver}'  im- 
portant, for  it  supports  the  view  that  there  is  a  physiological  migration 
of  white  corpuscles  from  the  maternal  to  the  faHal  blooil.  Varaldo  also 
found  that  while  eosinophilic  leucocytes  were  met  with  botli  in  the 
arteries  and  vein,  and  that  while  the  blood  of  both  gave  the  io(lo|)hilic 
reaction  of  Ehrlich,  this  reaction  was  more  marked  in  the  blood  of 
the  vein,  and  the  leucocytes  which  contained  iodophilic  granules 
were  more  numerous  in  it.  It  would  appear,  therefore,  that  not 
only  do  leucocytes  pass  from  the  mother's  blood  to  that  of  her  fcctus 
to  be  retained  in  the  fa?tal  body,  but  that  the.se  white  corpuscles 
carry  with  them  and  in  tliem  certain  substances  whose  precise  nature 
is  yet  to  be  determined.  Again,  it  may  be  said  that  the  physiology  of 
the  frt'tus  ]ireseuts  problem  u])on  problem. 


f 


FffiTAL   RESPIRATION  14:5 


Respiration  in  the  Foetus. 

Respiration  in  the  ftctus  is  a  very  ditterent  function  from 
respiration  in  the  infant  and  adult;  it  is  carried  out  in  the 
placenta  instead  of  in  the  lungs,  and  the  gases  pass  from  maternal 
to  foetal  blood,  and  not  from  the  atmospliere  to  the  Ijlood.  The  red 
blood  corpuscles  of  the  mother  are  the  source  of  oxygen  for  the 
foetus  ;  they  represent  its  atmosphere.  Eespiration  by  the  placenta 
has  sometimes  been  compared  to  respiration  by  gills,  Init  the  re- 
semblance is  incomplete  and  the  comparison  inexact.  There  is  httle 
need  at  the  present  time  to  enter  into  the  reasons  which  can  be 
adduced  to  prove  that  the  placenta  acts  as  lungs  for  the  fcetus,  once 
a  greatly  debated  and  uncertain  question.  Suffice  it  to  keep  in  mind 
that  (1)  the  matrifugal  blood  in  the  umbilical  vein  is  more  arterial 
in  appearance  (although  the  difference  is  often  slight)  than  the 
matripetal  cun-ent  in  the  umbilical  arteries ;  (2)  re.spiratory  move- 
ments in  the  foetus  are  excited  by  interference  with  or  stoppage  of 
the  circulation  in  the  placenta  ;  (3)  oxy-hpemoglobin  can  be  detected 
by  the  spectroscope  in  the  blood  of  the  umbilical  vein ;  and  (4)  that 
experiments  upon  animals  have  definitely  proved  the  occurrence  of 
the  placental  gaseous  interchanges  in  them  which  constitute  respira- 
tion. Further,  it  has  been  sliown  that  the  current  may  occasionally 
be  reversed, and  tliat  oxygen  may  pass  from  the  foetus  to  the  mother; 
this  has  been  noted  in  asphyxia  of  the  mother  animal,  in  which 
case  the  blood  of  the  umbilical  vein  has  been  observed  to  become 
more  venous  in  appearance  than  that  of  the  umbilical  arteries ; 
the  commencement  of  artificial  respiration  of  the  mother  restored 
the  colour  of  the  blood  as  at  the  first.  There  are,  however,  many 
other  questions  concerning  foetal  respiration  about  which  little  or 
nothing  is  known ;  some  of  these  have  been  already  referred  to 
mider  the  characters  of  the  foetal  blood  {e.g.  the  respiratory  capacity 
of  the  fcetal  blood),  to  others  a  few  words  may  now  be  given. 
There  is,  for  instance,  the  question  whether  the  foetus  consumes 
much  oxygen  in  a  short  space  of  time,  or  whether  it  absorbs 
little.  Preyer  (Joe.  cit.)  is  of  opinion  that  it  does  not  consume 
much,  but  that  it  is  very  dependent  for  its  life  upon  what  it 
does  consume.  Then  there  is  the  i^roblem  of  the  continuance  of 
the  heart's  action  for  a  long  time  without  the  establishment  of 
pulmonary  respiration,  contrasting  with  its  short  continuance  in 
utero  after  the  cessation  of  the  placental  circulation  (e.g.  in  death  of 
the  mother).  Again,  there  is  the  great  mystery  of  the  mechanism 
by  which  the  oxygen  of  the  maternal  hemoglobin  passes  to  the 
fcetal  haemoglobin,  a  mystery  which  is  not  greatly  lessened  by  the 
know-ledge  that  there  is  more  ha?moglobin  in  the  fietal  than  in  the 
maternal  blood,  or  that  the  oxy-ha?moglobin  of  the  foetal  blood  is  a 
more  stable  compound  than  that  of  the  maternal.  Some  further 
problems  have  been  already  referred  to  in  Chapter  IV.,  namely,  the 
cause  of  the  first  inspiration,  and  the  meaning  of  the  occurrence  of 
intrauterine  respiration  (vagitus  uterinus) ;  but  a  word  must  be  said 


144  ANTKNATAI.    I'A  THOLOCIV    AND    HYCilKNK 

ill  passiii.n'  concerning'  the  (iliservaliniis  of  Fcrroni  mi  the  ihytlniiical 
movements  of  the  fo'tus  still  in  ntero.  Ferroni  {Ann.  di  ontrt.,  xxi. 
897,  1899)  has  fcnuid  tliat  in  additiDii  to  the  rotatory  or  revolutionary 
movements  of  the  fu'tus,  and  those  due  to  extension  and  tiexion  of 
the  limhs  and  trunk,  there  are  others  of  a  rhythmical  kind  of  which 
tracings  can  be  obtained  liy  means  of  a  graphic  apjiaratus.  These 
movements,  which  occur  at  any  rate  in  the  three  last  months  of 
fietal  life,  had  been  previously  observed  by  Meiniann,  Ahlfeld,  Eeu- 
bold,  Weber,  Bar,  Pestalozza,  Duci,  and  others;  and  various  theories 
had  been  advanced  to  explain  their  nature.  Ferroni  agrees  witli 
Pestalozza  and  Duci  in  their  division  of  the  movements  into  two 
groups,  in  one  of  which  the  tracing  shows  sharj)  elevations  and  de- 
pressions, while  in  the  other  it  exhibits  nothing  more  than  a  series 
of  undulations.  In  the  former  tracings,  the  elevations,  sometimes 
with  a  sharp  apex  and  sometimes  with  a  blunt,  are  followed  by 
pauses,  while  in  the  latter  the  undulations  are  pi-actically  continuous. 
The  frequency  of  the  former  is  from  15  to  34  per  minute,  and  of  the 
latter  from  40  to  75  per  minute.  They  are  not  pathological  iihcno- 
mena,  for  the  mothers  and  also  the  foetuses  were  generally  found  to 
be  perfectly  healthy.  Both  kinds  of  tracings  are  doubtless  due  to 
rhythmical  movements  of  the  fa?tal  thorax,  and  not  to  transmitted 
pulsations  of  the  maternal  aorta ;  the  former  are  possiljly  of  the 
nature  of  singultus  (clonic  contractions  of  the  diaphragm),  while  the 
latter  are  supjiosed  to  be  intrauterine  respiratory  movements  (super- 
ficial and  regular).  Sometimes  the  two  kinds  have  been  found  com- 
bined in  one  tracing.  From  the  present  standpoint  these  movements 
are  of  interest  as  proof  that  even  before  birth  the  fcetus  makes  respira- 
tory movements,  practises,  as  it  were,  thoracic  gymnastics  in  ])re- 
paration  for  the  great  extrauterine  function  of  atmospheric  respiration. 
Whether  these  movements  are  powerful  enough  to  draw  liquor 
amnii  into  the  lungs  or  stomach,  must  be  left  for  the  mean  time 
imcertain ;  but  there  can  be  no  doubt  that  movements  of  a  similar 
kind  are  set  up  immediately  after  the  expulsion  of  the  foetus  from 
the  maternal  passages,  and  have  as  their  result  the  drawing  of  air 
into  the  lungs.  There  is  here,  then,  further  proof  that  nature  makes 
no  leaps  ("  non  facit  saltus  "),  but  prepares  Ijeforehand  for  the  transi- 
tions of  life  and  even  for  those  of  them  which  seem  at  first  sight  so 
abrupt  as  does  the  establishment  of  pulmonary  respiration  in  place 
of  placental.  She  makes  the  necessary  transitions  easy.  Tiul\-, 
birth  marks  not  a  beginning  but  a  stage  in  life's  journey. 


CHAPTER   X 

Physiology  of  the  Fa'tus  {ront.)  :  Tempeiature  of  the  Fu-tus  ;  Chemical  Com- 
position of  Fiftus,  Placenta,  and  Liquor  Arauii ;  Nutrition  of  the  Fa'tus,  Ijy 
Liquor  Amnii,  Umbilical  Vesicle,  and  Placenta  ;  Secretions  of  the  Fu-tus, 
Hepatic,  Buccal,  Gastric,  Pancreatic,  etc.  ;  Excretions  of  the  Fcetus,  In- 
testinal, Renal,  Placental  ;  Passage  of  Substances  from  Ftetus  to  llother  ; 
Internal  Glandular  Secretions  in  Fo-tus,  of  Thymus,  Thyroid,  Suprarenal 
Capsule,  and  Pituitary  Body  ;  Growth  of  the  Fiutus,  Determining  Factors  ; 
Movements  of  the  Fiutus  ;  Sensation  in  the  Fietus. 

The  functions  of  circulation,  blood-formation,  and  respiration  in  the 
fcetus,  have  presented,  as  has  been  shown,  many  difficult  C|uestions  for 
solution  ;  but  yet  more  difficult  ones  are  bound  up  with  the  phenomena 
of  antenatal  tissue  metabolism,  secretion,  excretion,  and  innervation. 
There  is,  for  instance,  the  nutrition  of  the  fcetus,  about  which 
Lobstein  wrote  that  it  was  "  less  hypothetical  than  the  suljject  of 
generation,  but  not  perhaps  in  a  much  more  satisfactory  state  " ;  and 
these  words,  which  were  penned  nearly  one  hundred  years  ago  (Dis- 
sertation sur  la  nutrition  du  fietus,  Strasbourg,  1802),  might  almost 
be  repeated  at  the  present  time,  for  although  observations  have  been 
multiplied,  of  actual  facts  there  is  no  great  abundance.  A  century 
ago  there  were  those  who  held  that  the  nourishment  of  the  fu?tus  was 
accomplished  by  means  of  the  lic^uor  amnii,  but  did  not  know  whence 
it  came ;  there  were  also  those  who  believed  that  it  was  brought 
al)0ut  hj  a  communication  between  the  placenta  and  the  wall  of  the 
uterus,  Ijut  did  not  know  how  the  communication  took  place ;  and 
there  were  those  who  ascribed  it  to  the  lymphatic  vessels  of  the  um- 
bilical cord,  but  were  not  sure  that  these  vessels  existed.  Lobstein's 
criticism  might,  with  a  slight  change  in  terminology,  be  directed 
against  the  teachers  of  obstetrics  of  to-day.  Nevertheless,  there  ha.s 
been  progress.     Let  us  see. 

Temperature  of  the  Foetus  in  Utero. 

The  observations  which  have  been  made,  many  of  them  with  great 
care,  upon  the  temperature  of  the  foetus  in  the  uterus,  or  in  the  act 
of  expidsion  from  the  uterus,  throw  a  somewhat  unexpected  side  light 
upon  the  problem  of  tissue  metabolism  in  the  unborn  infant.  These 
observations  include  the  experimental  work  upon  foetal  rabbits  and 
guinea-pigs,  carried  out  by  Euuge  and  Preyer  (op.  cit),  as  well  as  the 
estimation  of  the  rectal  and  buccal  temperature  in  the  human  subject 
during  and  immediately  after  birth,  made   by  Schaefer,  Schroder, 


14(3  ANTI'.NATAI,    I' All  l()I,(  )(i^■    AM)    1 1  V(  ilF.M', 

Wui'.sti'f,  1111(1  iiKire  recently  by  Vicarelli  (Air/i.  i/al.  dc  hio/.,  xxku. 
65,  1899).  Tliure  are  two  aspects  of  this  subject  which  may  be  con- 
sidered :  the  first  is  tiie  relation  of  the  maternal  temperature  to  that 
of  the  fcctus  ;  and  the  second  is  wliat  may  be  called  the  temperature 
proper  to  the  foetus  itself.     It  is  necessary  to  look  at  both  these  as])ects. 

It  has  been  found,  cliieHy  by  experiments  upon  animals,  that  the 
temiierature  of  tlie  fo'tus  falls  and  rises  accordinfi  as  the  nidtlier 
animal  loses  or  gains  lieat.  In  the  human  subject  the  increased 
rapidity  of  the  fcetal  heart  in  cases  of  fever  in  the  mother  pmliably 
points  to  the  same  relation.  Further,  as  it  is  not  easy  for  tlie  foetus 
in  its  secluded  position  in  utero  to  lose  heat,  it  may  be  concluded 
that  its  temperature  will  generally  be  above  that  of  the  mother.  With 
a  maternal  temperature  of  42°  C,  or  slightly  more,  the  foetus  will  die; 
and  even  40°  C.  will  become  a  danger  to  it,  for  the  reason  that  it 
doubtless  means  a  higher  figure  for  the  infant  in  utero  than  for  the 
mother.  Of  cour.se  the  period  of  persistence  of  the  high  temperature 
must  be  taken  into  account,  and  it  has  been  found  that  fo'tal  guinea- 
pigs  and  rabbits  are  able  to  sujipurt  a  temperature  of  41"  C  f<ir  two 
hours,  and  considerably  higher  temperatures  for  shorter  intervals  of 
time.  It  has  been  shown  experimentally,  also,  that  foetal  guinea-pigs 
support  chilling  of  the  mother  animal  very  well,  a  fall  of  as  much  as 
6°  C  in  half  an  hour  not  proving  fatal.  The  fictus,  then,  loses  and 
gains  heat  easily  and  rajiidly,  and  the  conclusidu  drawn  by  Preyer  is 
that  it  does  not,  while  in  utero,  possess  a  heat-regulating  mechanism. 

With  regard,  in  the  second  place,  to  the  proiluction  of  heat  by 
the  fcetus  itself,  a  large  number  of  observations  has  been  carried  out 
upon  the  human  fcctus  during  labour — a  thermometer  being  placed 
in  the  anus  in  breech  presentations  and  in  the  mouth  in  face  cases, 
while  another  (curved)  thermometer  was  inserted  into  the  uterus,  oi- 
simply  put  into  the  vaginal  canal.  The  result,  brietly  stated,  of  the 
experiments  has  been  to  prove  that  the  living  ftetus  constantly  possesses 
a  higher,  but  only  a  slightly  higher  temperature  than  the  containing 
uterus  and  than  the  vagina.  The  difference  has  not  been  found  to  be 
great — on  an  average  from  one  to  two-tenths  of  a  degree  Centigrade ; 
Ijut  it  was  practically  constant  in  favour  of  the  foetus.  The  temjterature 
of  the  liquor  amnii  has  been  found  to  be  intermediate.  In  a  dead 
fictus,  the  thermometer  in  the  cranial  cavity  (it  was  a  case  of 
craniotomy)  showed  a  lower  temperature  than  that  of  the  uterus 
(Vicarelli,  loc.  cit.).  Even  the  new-born  infant,  innnediately  after  its 
expulsion,  shows  a  temperature  sliglitly  higher  than  that  of  the 
mother's  uterus :  but  soon  thereafter  there  is,  as  is  well  known,  a 
very  striking  loss  of  heat  from  exposure  to  the  cold  air,  evaporation 
of  water  from  the  skin,  etc.  It  is  interesting  to  note  that  it  has  been 
found  that  there  may  be  the  difference  of  from  two  to  three-tenths  of 
a  degree  between  the  temperature  of  twins ;  further,  well-developed 
infants  have  shown  a  slightly  higlier  tem]ierature  than  weakly  ones. 
From  all  these  observations  it  may  lie  concluded  with  some  degree  nf 
assurance  that  the  fcctus  in  utero  not  only  receives  heat  fnnn  the 
maternal  j>arts,  but  is  also  to  some  extent  a  source  of  heat  itself.  Tlir 
high  temperature  of  the  foetus  proves  that  metabolism  is  going  on  in 


CHEMICAL   COMPOSITION    OF   F(KTUS  147 

it,  that  there  is  a  certain  amount  of  tissue  respiration  going  tni,  a 
conchision  which  is  strengthened  by  the  fact  that  such  products  (if 
oxidation  as  creatin,  liypoxanthin,  urea,  uric  acid,  and  carljonic  acid, 
are  found  in  it.  Proljably,  as  Preyer  Ijelieves,  fa>tal  oxidation  is 
feeble  ;  but  it  is  certainly  present.  Possibly  foetal  metabolism  may 
be  found  to  have  much  in  common  with  the  tissue-changes  of  hiber- 
nating animals.  At  any  rate,  there  is,  in  this  phenomenon  of  beat- 
formatidu  in  tlie  tVetus,  a  further  example  of  the  curious  blending  of 
dependence  upon  the  maternal  processes  and  independence  of  them, 
which  is  so  characteristic  of  the  life  of  the  unborn  infant. 

Chemical  Composition  of  the  Foetus,   Placenta,  and 
Liquor  Amnii. 

The  consideration  of  the  chemical  composition  of  the  foetus  and 
its  anuexa,  although  not  yet  possible  with  completeness  and  accuracy, 
is  nevertheless  calculated  to  throw  further  side  lights  upon  this  so 
intricate  subject  of  the  nutrition  of  the  unborn  infant.  In  a  matter 
with  this  degree  of  complexity  and  obscurity,  all  side  lights,  even  if 
only  rush-lights,  are  to  be  welcomed. 

The  foetus,  according  to  Fehling's  tables,  contains  at  the  full  term 
74-4  per  cent,  of  water  and  25'6  per  cent,  of  fixed  substances,  while  in 
the  adult  body  the  proportions  are  58'5  per  cent,  of  water  and  41 '5  per 
cent,  of  fixed  substances.  As  the  steps  of  fcetal  development  are  retraced, 
the  amount  of  water  in  the  foetal  organism  increases,  being  82-9  per 
cent,  at  the  eighth  month,  about  83  per  cent,  at  the  seventh,  about 
86  per  cent,  at  the  sixth,  from  89  to  90  per  cent,  at  the  fifth,  about 
91  per  cent,  at  the  fourth  month,  and  97'o  per  cent,  at  the  sixth 
week.  In  fact,  as  has  been  pointed  out  by  Fehling,  the  foetus  at 
the  second  month  of  antenatal  life  (neofoetal  period)  contains  a 
larger  proportion  of  water  than  the  blood,  mucus,  and  milk,  and  indeed 
resembles  lymph  in  this  particular.  With  regard  to  the  mineral 
constituents,  there  is  an  increase  during  ftetal  life  from  0-001  per 
cent,  of  the  total  weight  at  the  sixth  week  to  2'55  or  3  per  cent,  at 
the  full  term.  The  fat  increases  from  0'57  per  cent,  at  the  fourth 
niiinth  to  2'44  per  cent,  at  the  eighth  month,  and  94  per  cent,  at  the 
full  term  :  and  the  albuminous  substances  from  4-87  per  cent,  at  the 
fourth  month  to  11 '8  per  cent,  at  the  full  term  of  pregnancy.  These 
figures  cannot  be  taken  as  in  any-  sense  final,  as  the  number  of 
analyses  made  is  still  very  small,  and  each  chemical  constituent 
would  require  to  be  taken  by  itself  and  carefully  investigated  under 
different  conditions  as  to  nutrition,  etc.  Some  work  of  this  kind  has 
lieen  done ;  for  instance,  Thiemich  {CentrlU.  f.  Fln/sioL,  xii.  850, 
1809)  has  endeavoured,  in  the  case  of  foetal  dogs,  to  ascertain  the 
influence  of  the  nourishment  of  the  mother  upon  the  fat  of  the  foetus, 
and  has  found  that  tlie  kind  of  fat  given  in  the  food  does  not 
apparently  affect  the  fat  of  the  foetus ;  he  concludes  that  the  fat  of 
the  foetus  is  not  at  all,  or  only  in  small  part,  derived  from  the  fat  of 
■the  food  given  to  the  mother-animal.  L.  Hugoimenq,  also,  has 
specially  carried  out  a  series  of  researches  on  the  mineral  constituents 


148 


ANTKNAIAL    I'ATHOl.OCi'i     AND    HVCIKNK 


1 


of  the  huiuuu  I'n-tus  am 
g^n.,  i.,  p.  703,   1899: 


uc\v-lMiru  infant  (Jonni.  ih'  physiol.  ct  dc  path. 
pji.  1,  509,  1900),  and  has  elicited  some 


interesting  facts.  Tlie  fcetnses  cremated  varied  in  age  from  four  and 
a  lialf  months  to  full  term,  and  were  eight  in  nunilier.  It  was  found 
from  these  analyses  that  tiie  fixation  of  mineral  elements  was  little 
marked  in  the  beginning  of  antenatal  life,  and  very  marked  towards 
the  end  of  it:  that,  as  a  matter  of  fact,  the  global  weight  of  stilts 
fixed  ill  tlie  three  last  months  of  pregnancy  was  about  twice  as  great 
as  that  in  the  six  first  mouths;  and  that  at  the  time  of  birth  the 
f(Etus  had  subtracted  about  100  grms.  of  minerals  from  the  maternal 
organism.  In  a  fo-tus  of  four  and  a  half  months,  weighing  522  grms., 
the  ashes  weighed  140024  grins.,  while  in  a  full-time  infant  of  3300 
grms.  the  weight  of  the  ashes  was  1061630  grms. ;  in  a  fcetus  of  sLx 
months,  weighing  1105  grins.,  the  mineral  constituents  weighed 
30'7705  grms.  The  great  fixation  of  minerals  in  the  three  last 
months  is  therefore  undoubted,  if  it  is  permissible  to  ilraw  deductions 
from  one  series  of  estimations.  The  iron  is  an  important  mineral 
constituent,  and  was  therefore  specially  investigated  by  Hugounenc|. 
He  found  that  its  fixation-law  was  the  same  as  that  of  the  minerals 
generally,  viz.  twice  as  much  was  fixed  during  the  three  last  months 
as  during  the  whole  preceding  period  of  antenatal  life.  In  the  full- 
term  fcctus  the  total  (juantitv  of  iron  varied  from  0'383  to  0'421  grm. 
of  FejOj,  or  from  0-268  to  0"-294  grm.  of  the  metal  (about  0-397  per 
cent,  of  the  ashes  being  FejOj).  It  was  calculated  that  aljout  50  per 
cent,  or  60  per  cent,  of  the  iron  was  contained  in  the  blood  and  the 
rest  in  the  tissues ;  of  the  tissue-iron  most  would  be  in  reserve  ill 
some  organ,  e.g.  the  liver  or  spleen.  It  is  supposed  that  this  reserve 
iron  is  to  make  up  for  the  lack  of  the  metal  in  the  mother's  milk,  for 
it  has  been  observed  that  human  milk  does  not  in  its  mineral  con- 
stituents exhibit  the  same  parallelism  with  the  ashes  of  the  fa?tus  as 
does  the  milk  of  some  of  the  lower  animals,  a  parallelism  which  has 
been  sometimes  termed  Bunge's  law.  An  interesting  comparison  in 
tabular  form  of  the  mineral  constituents  of  human  milk  and  of  a  full- 
time  human  ftetus  is  given  by  Ilugouueuq,  and  may  be  reproduced 
here : — 


Anhydrous  phosphoiic  acid  (P.,0-,      .  So '28  per  cent. 

Lime(CaO)       .         .         .       ".'       .  40-48 

Magnesia  (MgO)         .         .         .         .  1-51       ,, 

Chlorine  (CI) 4-26 

Anhydrous  sulplmric  acid  (SO.,).         .  1-50       ,, 

i  Pero.xideofiron  (Fe..O.,)     .       '.         .  0-39        „ 

Potash  (K.,0)     .        '.  ■       .         .         .  6-20 

Soda(Na.jO) 8-12 

Anliydrous  carbonic  acid  (CO.j) .         .   '    1-89       „ 


21 -30  per  cent. 
14-79 
2-87       ,, 
19-73       ,, 

0-18       ,, 
1  35-15 
10-43 


The  storing  up  of  iron  in  the  fiTtus  during  the  third  trimester  of 
pregnancy  is  at'compauied  by  a  diminution  in  the  maternal  reserve  of 
that  metal.     This,  at  any  rate,  has  been  proved  for  the  guinea-pig  by 


CHF.MISTRV   OF    PLACENTA 


149 


Charriii  and  Levaditi  {Jonrn.  dc  j^hi/siol.  et  de  jxifh.  ghi.,  i.,  p.  772, 
1899).  These  observers  found  no  appreciable  difference  in  the  iron 
constituents  of  the  liver  in  the  pregnant  animal,  but  in  the  spleen 
a  diminution  was  demonstrable  both  chemically  and  histologically. 
The  foetal  hypersiderosis  is  accompanied,  therefore,  by  a  maternal 
hyposiderosis ;  and  it  may  lie  remarked  in  jiasaing  that  it  is  possible 
that  this  state  of  the  mother  in  pregnancy  may  predispose  her  to 
amiemia  and  greater  liability  to  infection. 

A  few  words  must  now  be  said  regarding  the  other  mineral  con- 
stituents of  the  foetus,  and  we  still  make  use  of  the  analyses  of 
Hugounenq  {loc.  cit.).  The  following  table  gives  the  percentage 
amounts  of  the  various  substances  for  100  grms.  of  ashes  in  fcetuses 
I  if  difierent  ages : — 


.Sex      . 

F. 

F. 

F. 

F. 

F. 

F. 

M. 

Age      . 

4-4i 

4i-5 

5-5A 

6 

6i 

Term. 

Term. 

Weight  in  kgs.     . 

0-522 

0-570 

0-80'0 

1-165 

1-285 

2-720 

3-300 

Ashes  in  grnis.      . 

14-0020 

14-7154 

18-3752 

30-7705 

32-9786 

96-7556 

106-163 

CO.J      . 

— 

1-50 

0-96 

0-90 

0-32 

1-89 

1-16 

CI        .        .        . 

8-99 

9-91 

8-59 

7-75 

8-53 

4-26 

4-54 

P,05      . 

34-74 

.32-33 

34-36 

34-94 

35 -.39 

35-36 

36-26 

SO,      . 

T-46 

1-27 

1-80 

1-78 

1-46 

1-53 

1-23 

CaO     . 

32-60 

38-21 

32-50 

34-64 

34-13 

40-55 

40-68 

MgO    .         . 

1-74 

— 

1-58 

— 

1-17 

1-51 

— 

KoO     .         .         . 

9  •12 

1-21 

8-28 

7-21 

8-45 

6-20 

7-56 

Na„0   . 

12-23 

13-75 

12-62 

10-62 

10-95 

S-12 

5-96 

FeA  . 

0-43 

0-33 

0-40 

0-39 

0-38 

0-39 

0-40 

The  predominance  of  the  soda  over  the  potash  is  to  be  accounted 
fur  by  the  relative  abundance  of  cartilage  in  the  foetus;  and  the 
marked  increase  in  the  potash  in  the  last  weeks  is  due  to  its  presence 
in  the  red  blood  corpuscles  and  in  striated  muscle.  In  the  second  half 
of  pregnane}-  the  fixation  of  phosphoric  acid  shows  inconsiderable 
variations ;  on  the  contrary,  the  proportion  of  lime  increases  greatly  in 
the  last  month,  so  that  at  the  end  of  antenatal  life  the  foetus  assimilates 
moi-e  lime  than  phosphoric  acid.  Consequently,  it  follows  that  the 
unborn  infant  does  not  assimilate  all  its  phosphate  of  lime  in  that 
form,  but  fixes  first  the  phosphoric  acid  (as  nuclein  or  lecithin),  and 
then  the  lime.  If  the  alkaline  bases,  the  phosphoric  acid,  and  the 
lime  be  left  out  of  account  (and  their  variations  are  due  to  the 
development  of  the  red  blood  corpuscles  and  the  bone),  the  centesimal 
composition  of  the  ashes  of  the  fa?tus  remains  fairly  constant  during 
the  second  half  of  intrauterine  existence,  although,  of  course,  the 
total  amount  of  the  mineral  constituents  increases  much  in  the  last 
weeks.  This  is  a  conclusion  of  some  importance  in  approaching  the 
problem  of  fcetal  nutrition. 

It  is  a  remarkable  fact  that  the  analysis  of  the  placenta  has  been 
almost  entirely  neglected ;  it  is  only  within  recent  years  that  any 
attempt  has  been  made  to  supply  this  defect  in  our  knowledge  of  the 
chemistry  of  generation.  To  V.  Grandis  (Arch.  ital.  de  biol.,  xxxiii., 
pp.  429,  439,  1900)  and  P.  Sfanieni  (An7i.  di  ostet,  xxi.  851,  1899,  and 
xxii.  1009,  1900)  we  are  indebted  for  some  careful  estimations  of  the 


150 


ANIKNATAI.    PA  11  lOI.OdV    AND    HVdlKNl-: 


cuuipusiliuii  111'  tliL'  iilaceiila.  There  were  ditlicullies  iu  the  way  of 
an  exact  analysis,  <v/.  the  imiHissibility  of  draining'  oil'  all  the  fcEtal 
blood  from  the  organ;  hut  Sfanieni  believes  that  the  figures  in  the 
following  table  show  not  only  the  composition  of  the  fietal  blood 
and  the  true  placental  tissue,  but  also  the  differences  between 
them : — 


Placenta. 

Fietal  Blood. 

■\Vater 

83-67  lier  cent. 

78-52  per  cent. 

Solids 

16-32 

21-47 

Organic 

ir.-4.-) 

20-72 

luorganic    . 

0-86 

0-74 

Soluble  salts 

0-73         „ 

0-62 

Insoluble  salts    . 

0-13 

0-12 

The  reaction  of  the  placental  tissue  was  neutral.  It  is  noteworthy 
that  the  amount  of  water  contained  in  the  placenta  is  very  large  (the 
percentage  given  by  Grandis,  83'S9,  is  practically  the  same  as  that  of 
Sfameni) :  in  this  respect  the  organ  stands  midway  between  renal 
tissue,  with  82-7  per  cent,  of  water,  and  the  grey  matter  of  the  cerebral 
cortex,  with  85-8  per  cent.  Of  the  substances  removed  by  extraction 
(1-925  per  cent.,  according  to  Grandis),  most  are  albuminous  in  their 
nature,  and  only  a  smiill  jjart  is  true  extractive.  The  conclusion 
seems  to  be  clear  that  the  placenta  contains  easily  ditl'usible  album- 
inous substances,  which  may  be  carried  without  difficulty  from  it  by 
a  physiological  solution  circulating  in  the  vessels ;  Grandis,  however, 
does  not  attempt  to  decide  whether  these  are  elaliorated  in  the 
placenta  or  come  from  the  mother.  Sfameni  has  shown  tliat  the 
placenta  contains  nucleon  (i)hospho-carnic  acid),  but  not  in  such 
amount  as  does  the  foetal  blood.  Grandis  has  made  a  sjiccial  analysis 
of  the  ashes  of  the  after-birth,  which  amount  to  TOTo  per  cent.  The 
following  table  gives  the  percentage  composition  of  the  ashes : — 


Placental  .\shca. 

Albuininous  Ashes  extracted 
from  unii-rigated  Placenta. 

Alhuminous  Ashes  from 
irrigated  Placenta. 

CI 

11-4 

— 

—                         1 

s. 

0-204 

- 

- 

Na 

24-93 

0-251 

0-728 

K. 

6-57 

- 

- 

POj       . 

33-46 

55-18 

14-5 

CaO      . 

2-32 

— 

CHEMISTRY   OF   LIQUOR   AMXII  151 

The  chief  facts  brought  out  by  this  analysis  are — (1)  the  large 
(luautity  of  phosphorus  found  ;  (2)  the  extractibility  of  most  of  the 
phiisphorus-containing  matters  with  water,  and  the  precipitation  of 
these  with  the  albuminous  substances ;  (3)  tlie  preponderance  of  soda 
over  potash ;  and  (4)  the  large  quantity  of  lime.  An  excess  of  lime 
may  show  itself  Ijy  concretions  on  the  maternal  surface  of  the  placenta, 
and  Sfameni  points  out  that  these  concretions  do  not  disturb  the 
growth  of  the  fcetus,  that  in  fact  the  more  insoluble  salts  there  are  in 
that  organ  the  heavier  the  infant.  I  can  support  this  observation, 
for  I  met  with  a  placenta  with  concretions  some  years  ago,  and  the 
fietus  was  markedly  large  and  healthy. 

It  is  possible  that  before  these  sheets  have  passed  out  from  the 
press  further  analyses  of  the  placenta  may  have  been  made,  supporting 
or  contro\'erting  the  conclusions  which  have  been  stated  above ;  in  the 
meantinre,  it  is  to  be  noted  that  the  chemical  investigations,  so  far  as 
they  have  been  carried,  go  to  show  that  the  placenta  is  something  more 
than  a  means  of  communication  between  mother  and  foetus,  somethmg 
more  than  a  mechanical  filter, — that  it  is  in  fact  a  special  organ,  con- 
sisting in  great  part  of  highly  diHerentiated  tissue  (epithelial  in  type). 

Tlie  liquor  amnii,  unlike  the  placenta,  has  often  been  the  subject 
of  chemical  analysis.  The  reason  is  not  far  to  seek.  The  amniotic 
fluid  has  been  the  central  position,  so  to  speak,  around  which  the 
great  l)attle  of  the  manner  of  fcetal  nutrition  has  raged.  Has  this 
tiuid  or  has  it  not  a  power  of  nourishing  the  fcptus  ?  Whence  comes 
it  ?  Is  it  of  foetal  or  maternal  origin  ?  Does  it  or  does  it  not  contain 
the  renal  excretion  of  the  foetal  kidneys  ?  Is  it  swallowed  by  the 
fo?tus  ?  These  and  many  other  allied  questions  have  lieen  asked  and 
variously  answered,  until  the  literature  on  this  suliject  has  grown  to 
great  dimensions.  Further,  the  questions  are  of  no  recent  origin,  but  are 
almost  as  old  as  Obstetrics  itself,  for  till  the  nature  of  the  placenta  was 
to  some  extent  understood  the  amniotic  fluid  seemed  a  probable  enough 
food  for  the  unborn  infant.  There  has  always  been  much  discussion 
about  the  liquor  amnii,  "  de  aquis  in  cpiibus  fcetus  humanus  quasi 
natat,"  as  the  old  writers  used  to  put  it.  Manifestly  the  chemistry  of 
the  fluid,  if  it  were  sufficiently  known,  will  throw  light  upon  all  the 
vexed  questions ;  man}'  analyses  have  thei'efore  been  made,  l:)ut  have 
not  as  yet  thrown  as  much  light  as  was  expected,  and  are  consequently 
being  continued,  with  what  result  time  alone  will  tell. 

In  the  meantime  it  may  be  stated  that  the  liquor  amnii  is 
chemically  a  serous  fluid  simply.  It  has  a  specific  gravity  of  1007  to 
1013  or  thereby,  and  a  slightly  alkaline  reaction.  It  varies  greatly 
in  quantity,  as  every  obstetrician  knows,  but  possibly  it  may  be  safe 
to  .say  that  usually  at  full  term  it  amounts  to  a  little  less  than  a 
litre ;  it  may  also  be  said  that  it  does  not  seem  to  bear  any  constant 
relation  to  the  weight  of  the  mother  or  of  the  fcetus  or  of  the  placenta, 
nor  to  the  length  of  the  umbilical  cord.  The  water  of  the  amniotic 
fluid  amounts  to  from  97  to  98  per  cent.,  and  may,  in  the  second  half 
of  pregnancy,  even  reach  99  per  cent. ;  alljumin  and  mucin  have  been 
found  in  it  to  the  extent  of  from  1  per  cent,  to  0-6  per  cent. ; 
extractives  from  0-7  per  cent,  in  the  earlier  months  to  0'03  per  cent. 


152  ANTKNATAI,    I'ATHOLOflY   AND    IIVCIKNK 

ill  the  latter;  and  suits  I'ruiii  U'9  per  cent,  to  O'.j  ]>fV  eeiit.  The  salts 
have  been  iuvestiii;ated  in  the  ease  of  the  liquor  ainnii  of  the  cow,  and 
have  been  found  to  consist  of  NaCl,  0'58(J  jier  cent. :  NaO,  0'l>67  per 
cent.;  KO,  0-060  per  cent.;  Ca,  0014  per  cent.;  Mg,  0-0038  per 
cent.  Urea  is  commonly  but  not  constantly  found,  but  apparently 
not  in  greater  quantity  than  is  common  in  serous  Huids  (from  0030 
per  cent,  to  0-045  per  cent,  at  the  close  of  pregnancy).  In  the  case 
of  a  diabetic  mother,  .sugar  was  met  with  in  the  liquor  amnii 
(H.  Ludwig,  Ccntrlhl.f.  Gynak.,  xi.x.  281,  1895)  to  the  amount  of  0-30 
per  cent.  Lockhart  Gillespie  {Trans.  Edinh.  Old.  Sue,  xi.\.  151,  1894) 
has  investigated  the  proteids  and  more  particularly  the  albumoses  of 
the  liquor  amnii  at  the  third  and  at  the  si.\th  month  of  pregnancy, 
and  has  found  a  trace  of  albumo.se  in  the  former  and  -1685  per  cent, 
(proto,  0485  :  hetero,  -045  ;  and  deutero,  -075)  in  the  latter :  the  total 
amount  of  proteids  (including  the  albumoses)  was  -3819  ]ier  cent,  at 
the  third  month  and  -9485  per  cent,  at  the  sixth.  In  the  latter,  also, 
■09  per  cent,  of  peptou  was  met  with.  (lillespie  is  of  opiniim  that  the 
presence  of  the  lower  forms  of  proteid  bodies  in  the  anniiotic  Muid, 
although  difficult  of  explanation,  may  be  due  to  the  action  upon  the 
albumin  of  digestive  ferments  similar  to  those  described  as  being 
present  in  pleuritic  or  ascitic  effusions.  Finally,  it  may  be  noted  that 
various  substances  given  to  the  mother  may  be  found  in  the  liquor 
amnii.  c.f/.  iodide  of  potassium. 

It  must  be  confessed  that  the  chemistry  of  the  liquor  amnii,  after 
all,  does  not  throw  much  light  upon  the  question  of  fcetal  nutrition — 
it  may  be  that  we  do  not  know  how  to  interpret  aright  the  meaning 
of  the  analysis.  It  certainly  .seems  to  be  of  inconsiderable  value  as  a 
food  stuH'  in  the  later  months  of  antenatal  life,  unless  partaken  of  in 
relatively  enormous  quantities  ;  but  it  may  play  an  important  part  as 
a  supply  of  water  to  the  growing  organism  at  all  periods  in  foetal 
existence.  Although  not  food,  it  may  very  well  be  drink  to  the 
unborn  infant.  It  may  also  be  .said  in  passing  that  its  chemistry 
does  not  clear  up  the  vexed  question  of  its  maternal  or  fa-tal  origin. 
Some  years  ago,  Krukenberg  {Arch./.  Gijna'l:,  xxii.  43,  1884)  wrote  in 
slightly  hopeless  fashion  :  "  Die  physikalisch-chemische  Untersuchung 
des  Fruchtwassers  giebt  also  keine  Auskunft  liber  die  Herkunft 
desselben";  and  the  same  judgment  might  be  pronounced  to-day — 
"  keine  Auskunft  iUier  die  Herkunft" — no  information  (or  little)  about 
its  origin,  although  for  other  reasons  we  are  inclined  to  regard  the 
liquor  amnii  as  of  mixed  origin,  partly  maternal,  partly  fu'tal. 

Nutrition  of  the   FcEtus. 

The  most  diHicuIt  prcibleni  in  fietal  ]ihysioliigy  is  doubtless  the 
nutrition  of  the  miborn  infant.  Xotwithstanding  its  exceeding  diffi- 
culty, it  has  from  time  inimemorial  attracted  investigators  and  ]ihilo- 
sophers,  and  their  work  anil  sjieculation,  if  they  have  accomplished 
nothing  else,  have  at  least  done  this :  they  have  demonstrated  its 
exceeding  difficulty.  Like  the  ]iroblem  of  the  exact  nature  of  repro- 
ductinn  and  of  the  origin  of  sex,  the  iiuestion  of  how  the  infant  grows 


NUTRITION   OF  THE   FCETUS  153 

in  the  wumli  lias  fascinated  and  iierplexed  generations  of  seekers  after 
truth,  but  has  not  discouraged  them.  Difficile  est,fateor,  sed  tcndit  in 
ardna  virtus. 

In  what  has  been  already  stated  with  regard  to  foetal  circulation 
and  the  chemistry  of  the  blood,  the  ftctal  tissues,  the  placenta,  and 
the  liquor  amnii,  the  way  has  been  paved  for  the  more  intimate  con- 
sideration of  the  central  problem  of  fcetal  nutrition.  The  wideuess  of 
the  problem  and  the  great  number  of  investigations  to  which  it  has 
given  rise  forljid  more  than  an  indication  of  the  salient  points  of  the 
theme.  Let  us  in  the  first  place  endeavour  to  clear  away  some  of  the 
difficulties,  by  discussing  in  order  the  liquor  amnii,  the  umbilical 
vesicle,  and  the  placenta  as  a  source  of  food-supply  to  the  f(ctus. 
Thereafter  we  may  look  at  the  matter  of  metabolism  in  the  fcetns  and 
the  question  of  tVctal  secretion  and  excretion. 

Whatever  may  be  thought  with  regard  to  the  nutritive  properties 
of  the  Uquvr  amnii,  there  can  be  no  doubt  that  it  plays  an  important 
part  in  antenatal  life.  It  is  an  organ  of  protection  to  the  fcetus, 
saving  it  from  shocks,  injuries,  changes  in  temperature,  and  excess- 
ive pressure ;  it  gives  freedom  of  mo\'ement  with  a  minimum  of 
muscular  effort  to  the  unborn  infant :  and  it  is  useful  as  a  fluid 
dilating  wedge  in  the  hours  of  partm-ition.  Does  it,  however,  serve 
any  other  purpose  or  play  any  other  part  in  intrauterine  existence  ? 
That  it  receives  excretions  from  the  fietal  skin  and  occasionally  from 
the  fcetal  kidneys  is  generally  admitted — epithehal  squames,  vernix 
caseosa,  and  hairs  are  met  with  in  it  as  well  as  the  products  of  renal 
activity  (urea,  kreatinin),  and  when  benzoic  acid  is  given  to  the 
pregnant  mother-animal  it  is  met  with  as  hippuric  aciil  in  the  liquor 
amnii  (Gusserow).  Further,  it  is  the  source  of  the  chief  water  supply 
of  the  tVetus  ;  this  also  cannot  be  doubted.  No  doubt  it  receives  some 
water  from  the  mother  by  the  placental  route  in  the  blood  of  the 
umbilical  vein ;  but,  as  has  been  seen,  the  composition  of  the  matri- 
fugal  blood  (in  the  umbilical  vein)  when  compared  with  that  of  the 
foetal  tissues  (vide  siqira)  proves  that  all  the  water  cannot  be  thus 
obtained.  Consequently,  it  follows  that  much  of  the  li(]uor  amnii 
must  lie  absorbed  through  the  fcetal  skin  (in  the  earlier  months  of 
fcetal  life),  and  swallowed  by  the  mouth  and  taken  into  the  stomach 
and  intestines  (in  the  later  months).  Of  the  swallowing  of  the 
liquor  amnii  there  can  be  no  doubt,  for  products  of  the  activity  of  the 
foetal  skin  (hairs,  epidermis,  vernix)  could  not  in  any  other  way  find 
entrance  to  the  intestinal  canal  and  be  discovered  as  constituents  of 
the  meconium.  It  may  be  granted,  then,  that  there  is  a  certain  cir- 
culation of  liquor  amnii  through  the  fcetal  tissues — a  swallowing  of  it, 
an  absorption  of  it,  and  an  excretion  of  it ;  and  it  is  probable  that 
there  is  a  circulation  of  it  through  the  maternal  organism  also,  that 
in  fact  the  liquor  amnii  is  being  secreted  and  absorbed  again  by  the 
maternal  tissues.  It  is,  therefore,  a  water  supply  to  the  fcetus.  Is  it 
also  a  food  supply  ?  It  must,  I  think,  lie  admitted  that  to  a  certain 
extent  it  is.  It  can  hardly  circulate  in  the  way  that  has  been 
described  without  losing  some  of  its  constituents  to  and  taking  up  new 
substances  from  the  foetal  tissues.     It  is  true  it  does  not  contain  much 


154  ANTKNAI'AI.    I'AIHOI.OCV    AND    HY(;IKNK, 

nutriment,  but  it  is  LMnially  true  that  it  contains  some;  and  if,  as  is 
extremely  ]irobablu,  it  is  al)S(irbe(l  and  swallowed  in  relatively  large 
amount,  tlie  i|uautity  of  food  that  is  thus  conveyed  to  the  fu'tus  may 
lie  not  incdMsiderable. 

The  part  played  by  the  uinhilical  rexiclc  or  }•! ilk-sac  in  the  nutri- 
tion of  the  human  fcctus  is  apparently  not  great.  At  any  rate  it  can 
only  be  of  use  to  the  fu-tus  in  the  early  weeks  of  fcetal  life,  for  it  soon 
is  left  behind  in  development,  and  can  scarcely  be  said  to  enlarge  at 
all  after  the  neofictal  ])eriod.  Nevertheless  there  is  evidence  that  in 
tiiese  early  weeks  it  contains  true  yolk,  and  it  is  tlierefore  more  than 
]irol)able  that  it  is  a  source  of  food  sujijily  to  the  organism  in  the 
transiticjn  jieriod  of  neofcetal  life,  if  not  later.  In  other  vertebrate 
foetuses,  the  yolk-sac,  as  every  student  of  Kmliryology  knows,  plays  a 
very  important  nutritive  function  ;  but  in  mammals  it  is  to  all  intents 
of  no  consequence  as  a  direct  source  of  food  supjily,  although  in  some 
mammals  it  takes  part  in  the  nutrition  of  the  ftetus  in  another  way,  tn 
be  now  referred  to.  In  the  Itodentia,  Inseetivoia,  and  t'liiroptera  the 
umbilical  vesicle  becomes  united  by  its  vessels  (vitelline  or  omphalo- 
mesenteric) with  the  diplo-trophoblast  (Hubrecht)  or  sub/.onal 
membrane  plus  epililast,  to  form  a  temporary  structure  connecting 
mother  with  ftetus,  the  vitelline  or  omphaloidean  placenta.  By  and 
by  the  vitelline  is  replaced  by  the  allantoic  placenta,  but  it  is  most 
important  to  remember  that  for  a  time  the  nourishment  of  the  fcetus 
is  carried  on  by  a  placenta  the  vessels  of  which  are  those  of  the  um- 
bilical vesicle.  1  have  elsewhere  (102)  shown  reason  for  supposing 
that  sometimes  at  least  a  vitelline  placenta  may  intrude  itself  into 
the  embryological  history  of  the  human  fietus,  that  in  the  sympodial 
nKjnstrosity,  and  possibly  in  other  terata  as  well,  the  allantoic  vessels 
do  not  develop,  and  yet  a  placenta  is  grown  which  carries  the  fo'tus 
to  the  full  term  of  gestation,  and  that  this  jilacenta  is  formed  by  the 
vascularisation  of  the  chorion  by  the  vitelline  vessels.  Further,  in 
the  non-placental  mammals,  such  as  the  Marsupials,  in  which  there  is 
no  true  placenta,  either  vitelline  or  allantoic,  the  organ  which  absorbs 
nourishment  for  the  t\etus  from  the  mnther  before  the  former  is 
transferred  to  the  marsupium,  is  the  umliilical  vesicle.  The  young  nf 
the  Marsupials  is  born  in  a  very  immature  condition,  but  through  the 
medimn  of  the  milk-nutrition  of  the  marsupium  is  carried  safely  nn  t" 
full  development.  Through  the  formation  of  a  vitelline  and  later  ni 
ail  allantoic  placenta,  the  })eriod  of  utero-gestatii m  in  the  higher 
mammals  can  be  prolonged,  the  fo'tus  can  be  more  fully  developed  in 
utero,  and  the  mammary  method  of  nutrition  can  be  ]iost]Mined  in 
a  later  date.  It  may  therefore  be  regarded  as  proliable,  both  on  the 
grounds  of  jihylogenesis  and  of  ontogenesis,  that  the  umliilical  vesicle 
and  more  particularly  its  ves.sels  play  a  certain  jiart  in  the  nutrition 
of  the  ftetus ;  normally,  however,  vitelline  nutrition  is  of  short  duration, 
being  limited  by  the  close  of  the  neofa^tal  period,  or  very  soon  there- 
after. With  some  forms  of  monstrosity  it  may  be  greatly  prnlongcd, 
and,  even  when  no  malformatidii  exists  in  the  infant,  jicrsistcnt  and 
pervious  vitelline  vessels  may  be  traced  in  the  cord  and  full-time 
lilaeenta,  and  these  may  ennlaiii  blmid.     An  example  of  these  per- 


NUTRITION   OF  THP:   F(KTL'S 


155 


manent  vitelline  vessels  I  met  with  some  years  ago ;  the  specimen  is 
here  figured  (Fig.  27).  More  recently  Bovero  has  described  a  similar 
case,  in  which  he  was  able  to  inject  the  vessels  {Intcrnat.  Monatschr.  f. 
Anat.  u.  Physiol.,  xii.  31,  1895). 

To  summarise  at  this  stage  in  our  consideration  of  the  subject  in 
hand :  the  liquor  amnii  is  a  certain  but  small  source  of  food  supply 
to  the  fwtus,  even  in  the  later  months ;  the  part  played  by  the 
nmbihcal  vesicle  and  its  vessels  is  under  normal  circumstances 
finished    in   the   early  weeks  of   utero-gestation,    but   may    be   less 


Fig.  27. — Placenta  with  persistent  Umbilical  Vesicle  (a),  and  vitflline 
vessels  {h,  h,  b,  h).     Reduced  by  about  one-tliird. 

temporary  under  certain  unusual  conditions.  IManifestly,  there  must 
be  some  other  organ  of  foetal  nutrition  which  has  not  yet  Ijeen  referred 
to,  for  it  is  impossible  to  accept  the  feebly  nutritious  liquor  amnii  and 
tlie  temporary  yolk-sac  as  sufficient  sources  of  food  for  the  rapidly 
growing  unborn  infant.  That  organ  is  universally  admitted  to  be  the 
placenta. 

The  reader  will  be  not  unprepared  for  the  conclusion  that  the 
placenta  is  the  chief  organ  of  nutrition  of  the  foetus ;  for  the  side 
lights  upon  the  subject  that  have  been  got  from  the  study  of  the 


loG  ANrKNATAI,    I'AI'IlOLfXlY    AND    HY(;iKNE 

tuiupeniluif  of  ihe  t'ci'Hi.s,  uf  tlic  chemical  analyses  iliat  liavo  lieen 
made  of  its  tissues  and  of  the  placental  sul>stance,  and  of  tlie  histology 
of  the  blood  of  the  nnihilical  vein  and  arteries,  have  all  tended  to 
throw  into  jironiinence  the  iilacental  factor  in  the  ])robleni.  At  the 
same  time,  it  must  he  admitted  that  most  of  the  evidence  which  we 
possess  is  of  the  indirect  kind ;  and  it  is  even  now  far  from  certain 
to  what  extent  the  placenta  acts  simply  as  a  transmitter  of  ])repared 
nourishment,  and  to  what  extent  it  is  also  an  organ  which  alters  the 
composition  of  the  food-stufis  coming  to  it  and  has  a  true  secretion. 
Much  yet  remains  to  be  done  Ijefore  these  problems  are  cleared  up; 
but  let  us  take  heart,  much  is  being  ilone — trniUt  in  nrdua  virtus. 
Let  us  consider  some  of  the  proofs  which  have  l)een  collected,  indirect 
although  they  may  be. 

There  is,  in  the  first  place,  evidence  that  in  tlie  human  subject 
certain  substances  pass  from  the  maternal  blood  through  the  placenta 
to  the  fcetus.  It  is  difficult,  however,  to  obtain  proof  of  the  passage 
of  the  substances  which  go  to  liuild  up  the  body  of  the  foetus ;  it  may 
be  necessary  to  suppose  that  all  the  chemical  constituents  which 
make  up  the  structure  of  the  body  of  the  unborn  infant  have  passed 
to  it  in  one  form  or  another,  and  in  one  chemical  combination  or 
another,  from  the  mother's  blood  through  the  placenta,  but  exact 
demonstration  is  really  impracticable,  for  we  cannot,  as  it  were,  ear- 
mark any  one  sul)stauce  in  the  maternal  dietary  and  recognise  it  again 
in  the  foetal  body.  Indirect  proof,  however,  is  forthcoming,  and  is 
indubitable.  Substances  which  do  not  normally  exist  in  the  fu'tal 
organism  can  be  administered  to  the  mother,  and  their  presence  can 
be  afterwards  demonstrated  in  the  ])lacenta  and  fcetus.  The  sub- 
stances which  have  been  employed  have  nearly  always  been 
medicinal;  and  chloroform,  salicylic  acid,  iodide  of  potassium,  alcohol, 
mercury,  and  methvlene-blue  may  be  mentioned  as  examples.  The 
chemical  substance  has  not  always  been  found  to  pass  to  the  infant 
(tluis,  all  ol}servers  are  not  agi-eed  as  to  the  transmissibility  nf 
mercury),  but  its  occasional  passage  is  really  all  that  is  needed  to 
prove  our  present  point,  which  is,  that  in  the  hunum  subject  soluble 
and  ditl'usible  substances  in  the  maternal  blood  may  pass  over  to  the 
fcetus  through  tlie  placenta.  Eecently,  Nicloux  {L'Oh^tetriquc,  Ann.  v., 
p.  97,  1900),  with  the  help  of  new  methods  and  improvetl  apparatus 
for  analysis,  has  given  conchusive  proof  tliat  alcohol  administered  to  a 
parturient  woman  one  ho\ir  or  so  before  her  delivery  can  lie  found  in 
the  blood  of  the  umbilical  cord.  Further,  the  transmission  of  certain 
diseases  from  mother  to  fcetus  in  utero,  c.//.  syiihilis,  malaria,  small- 
pox, is  evidence  that  the  suljstances  whicii  are  neither  nutritive  noi- 
soluble  may  jjass  through  the  placenta,  and  this  fact  may  be  lu^ld  to 
be  indirect  proof  of  fcetal  nutrition  liy  the  placental  route;  l)ut  tliis 
side  of  the  subject  is  not  at  present  em})hasised,  for  it  will  be  referred 
to  again.  The  analyses  of  the  blocxl  of  the  umbilical  vein  and  arteries 
as  carried  out  by  Varaldo  {loi\  cit.  suprx)  may  also  be  advanced  in 
support  of  Ihc^  contention  that  the  placenta  is  the  great  means  of 
transmitting  nutrinu'ut  to  the  fietus,  and  it  may  further  be  held  to 
give  a  hint  as  to  the  manner  of  its  transmission  ;  for  it  was  found  that 


NUTRITION   OF  THE   F(ETUS  157 

there  were  more  white  blood  corpuscles  in  the  bluod  of  the  uiiiliilical 
vein  than  in  that  of  the  arteries,  and  that  more  of  them  contained 
iodophilic  granules  in  the  former  than  in  the  latter.  It  seems,  there- 
fore, to  be  reasonaljle  to  conclude  that  some  of  the  leucocytes  are 
retained  in  the  fcetus,  and  that  they  may,  as  was  indeed  supposed  by 
earlier  observers,  be  carriers  of  nutriment. 

In  the  second  place,  experiments  upon  the  lower  animals  may  be 
adduced  as  giving  :nore  complete  proof  of  the  passage  of  certain 
chemical  substances  through  the  placenta,  from  mother  to  fcetus  via 
the  placenta ;  and  it  is  true  that  we  can  more  scientifically  regulate 
and  check  such  observations  than  we  can  the  clinical  researches  upon 
the  human  subject.  On  the  other  hand,  it  must  not  be  forgotten  that 
there  are  considerable  diH'erences  between  the  structure  of  the  human 
placenta  and  that  of  the  lower  mammals,  and  it  does  not  necessarily 
follow  that  what  is  demonstrable  in  the  case  of  the  rabbit  or  guinea- 
pig  will  be  true  for  the  infant.  Nevertheless,  these  experiments  have 
been  of  service,  and  by  their  means  it  can  be  asserted  that  such  sub- 
stances as  chlorate  of  potash,  iodide  of  potassium,  salicylate  of  soda, 
bromide  of  potassium,  lithium,  mercury,  antipyrine,  quinine,  arsenic, 
alcohol,  moi-phine,  copper,  lead,  benzoate  of  soda,  etc.  etc.,  occasionally, 
if  not  always,  pass  in  the  matrifugal  blood  stream  to  the  fcetus. 
Further, the  fact  that  sometimes  the  substance  experimented  with  could 
be  found  in  the  fa?tus  and  in  the  placenta  but  not  in  the  liquor  amnii, 
seems  to  exclude  the  possibility  of  the  liquor  amnii  being  more  than  a 
most  occasional  means  of  conveyance  of  materials  from  mother  to  foetus. 
Experiments  upon  animals  have  also  shown  that  bacteria  and  their 
toxines,  substances  which  differ  very  markedly  from  the  soluble 
and  diffusible  chemical  compounds  to  which  we  have  referred,  may 
pass  through  the  tissues  intervening  between  the  maternal  and  foetal 
bloods  in  the  placenta ;  it  is  true  that  they  do  not  always  so  pass,  and 
that  it  is  not  yet  known  what  circumstances  determine  their  passage 
or  non-passage,  but  their  occasional  transmission  is  further  proof  in 
support  of  tlie  belief  that  food  substances  may  also  reach  the  foetus 
in  this  way. 

In  the  third  place,  it  may  be  with  justice  alleged  that  the  placental 
route  is  really  the  only  one  by  which  nourishment  can  pass  to  the 
unborn  infant  in  the  later  months  of  pregnancy.  By  exclusion  we 
come  to  this  conclusion,  for  a  well-nourished  fcetus  may  be  found  with 
almost  entire  absence  of  liquor  amnii ;  or,  again,  although  there  Ije  a 
sulScient  quantity  of  amniotic  fluid,  the  fcetus  may  suffer  from  an 
imperforate  condition  of  the  cesophagus,  an  anomaly  which  of  course 
prevents  the  fluid  l.>eing  taken  into  the  digestive  tract,  and  yet  the 
nutrition  may  show  no  sign  of  having  been  interfered  with.  With 
regard  to  nourishment  by  the  umbilical  vesicle,  it  is  unnecessary  to 
point  out  that  such  a  method  is  inconceivable  in  the  later  montlis  of 
antenatal  life,  as  the  food  supply  contained  in  it  is  quite  inadequate. 
Teratology  furnishes  a  very  strong  argument  in  favour  of  the  view- 
that  the  placenta  is  not  only  the  chief  but  practically  the  sole  means 
of  the  transmission  of  nourishment  to  the  unborn  infant ;  for  foetuses 
so  deformed  as  to  possess  scarcely  any  organ  sa^'e  the  placenta,  or  a 


158  ANTI'.NAIAI,    I'A  THOI.OdV    AM)    IIVCilHNF, 

j)iirLiuii  of  the  iiLu-eiitii  nf  iumllun-  I'u'lus,  may  yet  lie  nt)urislie<l  and 
brouji;ht  lliruiigli  nine  niontlis  of  intnuiterine  existence  to  the  full 
term;  the  one  oii;an  which  is  essential  to  tiieir  nourishment  (1  say 
iiotliing  meanwhile  rej^arding  structural  integrity)  is  the  jdacenta. 
It  may  be  hazarded  tliat,  did  the  liuman  fietus  not  ])ossess  a  jilaeenta, 
it  would  1)e  imjHissible  for  it  to  1)8  carried  beyond  tlie  seeond  month 
of  antenatal  life  ;  it  is  the  evolution  of  the  placenta  that  has  pro- 
longed intrauterine  existence,  and  made  it  possilile  for  the  fo'tus  to 
be  much  further  advanced  in  develoinuent  wlien  born.  On  this  subject 
and  on  some  allied  iinestions  John  Beard  discourses  most  suggestively 
in  his  Certain  Problems  of  Vertebrate  Emhrijology  (Jena,  1890). 

The  ])lacenta,  then,  is  at  any  rate  a  transnutter  of  nourishment 
from  mother  to  fcetus.  But,  is  it  something  more  ?  Does  it  prepare, 
elaborate,  and  otherwise  alter  the  food-stuffs  passing  througli  it  ? 
There  is  undoulitedly  a  consideral)le  mass  of  evidence  to  show  that  it 
does  not  simply  permit  materials  to  pass  through  from  the  one  lilood 
to  the  other  by  the  plain  and  uncomplicated  laws  of  osmosis :  it 
plays  a  more  intricate  and  subtle  part  than  that.  It  has  a  certain 
selective  power,  as  is  shown  by  the  fact  to  which  reference  has  already 
been  made,  that  the  ([uality  of  urea  in  the  foetal  and  maternal  lilood 
is  not  the  same.  Further,  it  would  seem  that  a  larger  quantity  of 
one  chemical  substance  ])asses  from  nnjther  to  fcetus  at  one  time  in 
pregnancy  than  at  another,  for  in  the  later  months  there  is  a  marked 
increase  in  the  amount  of  ir<m  and  of  potash  and  lime  in  the  infant ; 
these  materials  are  needed  by  the  fu?tus  then  to  form  the  bones,  the 
red  corpuscles,  and  the  striped  muscles,  and,  perhaps,  to  make  up  for 
the  future  deficiency  in  iron  of  the  maternal  milk ;  and  the  jilacenta 
apparently  has  the  power  of  supplying  them  in  the  necessary  abund- 
ance. Again,  the  ])lacenta  would  seem  to  have  the  property  of 
storing  up  in  its  sulistance  certain  minerals,  e.g.  mercurj' ;  this,  at 
any  rate,  is  the  finding  of  certain  experiments  upon  guinea-pigs  made 
by  Porak  (Arch,  de  mid.  e.vp.  ct  d'anat.  path.,  vi.  192,  1894).  In  its 
])ower  of  storing  up  mineral  and  possilily  also  microl)ic  poisons  and  of 
fixing  glycogen,  the  ]ilacenta  resembles  the  adult  liver,  and  possibly 
it  may  possess  this  faculty  in  order  to  set  the  fietal  li\"er  free  for 
other  functions  (h;eniatopoiesis  ?).  We  must  a\-oid  "  the  guesser's 
darkening  of  knowledge,"  but  one  is  tempted  to  speculate  upon  many 
matters  concerned  with  the  part  played  by  the  placenta  in  fcrtal 
nutrition.  Does  it,  for  instance,  yield  a  special  secretion  to  the 
foetus  ?  Does  it  also  send  to  the  mother  an  internal  secretion,  as  has 
jjeen  suggested  by  Letulle  and  Xattan-L;irrier  {lor.  cit.),  a  secretion 
which  is  neither  glycogen  nor  fat  nor  mucin,  but  an  albuminoid  ?  Does 
it  in  any  degree  save  the  fcetus  from  the  ett'ects  of  maternal  mal- 
nutrition ?  Why  is  it  that  at  first  the  placenta  and  the  foetus  seem 
to  grow  almost  pari  paxgii.  in  wciglit,  while  later  in  antenatal  life  the 
former  scarcely  gains  at  all,  and  tliT"  lattci'  continues  to  increase  at 
a  wonderfully  rapid  rate  ?  Hier  reiht  wirklich  die  I'hysinlogie  des 
Embryo  Problem  an  Problem  ! 

The  matters  which  we  have  l)een  discussing,  ditlicult  and  almost, 
insoluble  thougli  they  may  well  appear,  must  nevertheless  yield  in 


SECRETIONS   OF  THE   F(ETL'S  159 

Cdiuple.xity  to  certain  nther.s  as  yet  liarely  touched  upon.  I  refer  to 
the  problems  of  the  metabolism  of  the  fietus,  its  intracorporeal 
as  distuiguished  front  its  placental  or  extracorporeal  biochemistry. 
That  the  fa>tus  does  not  act  simply  as  an  absorber  of  prepared 
nourishment,  is  certain ;  that  it  acts  to  a  certain  extent  inde- 
pendently in  the  building  up  of  its  own  tissues,  is  proved  by  its 
temperature  and  l)y  the  chemistry  of  its  excretions.  The  belief  is  also 
strengthened  by  the  study  of  its  secretions.  Let  us  consider,  there- 
fore, this  aspect  of  the  nutrition  of  the  fa>tus. 

Secretions  of  the  Foetus. 

The  great  size  of  the  liver,  and  the  fact  that  it  receives  the  purified 
and  food-containing  blood  from  the  placenta  before  it  can  reach  the 
other  organs  of  the  fu?tus,  lead  us  to  expect  that  this  gland  plays  a 
large  part  in  the  metabolism  of  the  body.  There  is  good  reason  to 
believe  that  this  expectation  is  well  founded.  The  presence,  for  in- 
stance, of  consideraljle  quantities  of  glycogen  in  the  ftetal  liver  at  liirth 
goes  to  show  the  activity  of  its  glycogenic  function  ;  at  the  same  time 
the  detection  of  this  material  in  most  young  I'cotal  tissues  {e.g.  muscle, 
heart),  and  its  production  in  the  placenta  diminish,  in  theory  at  least 
the  part  taken  by  the^  hepatic  cells  in  this  physiological  act.  Another 
sign  of  hepatic  functional  activity  is  found  in  the  presence  of  bile 
in  the  gall  bladder ;  api)arently  this  secretion  is  poured  out  from  the 
third  month  of  intrauterine  life  until  the  full  term.  It  would  seem 
also  that  it  is  really  bile,  for  it  contains  both  bile  acids  and  liile 
Colouring  matters,  although  bilirubin  is  proljably  not  produced  in 
appreciable  quantity  till  the  mid-term  of  pregnancy.  It  does  not,  at 
the  same  time,  appear  clearly  what  purposes  the  bile  serves  in  the 
fu;tal  economy,  for  it  can  hardly  play  a  great  part  as  an  intestinal 
antiseptic,  and  it  is  not  much  needed  in  digestion,  and  yet  its  early 
presence  indicates  some  functional  importance.  It  gives  to  the 
meconium  its  characteristic  dark  green  colour ;  so  much  we  are 
assured  of ;  what  else  it  does  in  fcetal  life  is  obscure,  "  bleibt  nnklar." 
It  may  be  worth  while  to  give  here  the  chemical  analysis  of  the  foetal 
liver,  as  determined  by  Doleris  and  Butte  {Nouv.  arch.  d'obstH.  et  dc 
(jynec.,  ii.  378,  1887) — 

AVater  .....  70-70  .     -* 

Solids  .  .  .  .  29-30 

Organic  substances    ....       27'981 
Inorganic  substances  .  .  .         1'319 

About  the  buccal  secretions  in  the  ftetus  little  is  known,  save  the 
fact  that  in  the  new-born  infant  the  presence  of  ptyalin  can  usually 
be  detected ;  but  why  there  should  be  at  the  end  of  ftetal  life  a  saliva 
with  an  amylolytic  power  which  will  not  apparently  be  needed  (under 
normal  circumstances  and  while  an  exclusive  milk  diet  is  maintained) 
till  several  months  of  postnatal  existence  have  passed,  is  a  hard  pro- 
Ijlem  even  among  proljlems  which  are  not  easy.  There  is  evidence 
that  the  buccal  secretions  (salivary  as  well  as  mucous)  are  not  free  in 


160  ANTFAA'IAI.    l'AllI()I.()(iV    AND    HVCIKNK 

thefd'tus;  Imt  it  is,  on  tln'otliei  hand,  imt  kunwii  tcp  what  extent  the 
inoutli  is  ke]it  lunist  by  the  iiigeslinn  of  liquor  anuiii.  It  is  possible 
that  a  small  amount  of  gastric  digestion  may  go  f)ii  in  fujtal  life  ;  for  in 
tiie  case  of  the  human  fcetus,  at  any  rate,  it  has  heen  noted  by  I)oleris 
and  Butte  {loc.  cit.)  and  others,  that  fibrin  may  be  digested  by  a  solution 
made  from  a  scra])ing  of  the  mucous  membrane  of  the  stomach  of  an 
infant  that  had  jierished  in  l)irth  (craniotomy).  Tejisine,  therefore, 
is  jireseiit  in  the  stomach  at  liirth:  and,  according  to  tlic  obsci'vations 
of  Kollikcr  and  Langendorti',  it  is  there  as  early  as  the  fourth  month 
of  intrauterine  existence.  It  is  safe  to  state,  in  this  connection,  that 
there  is  evidence  that  there  is  sutticieut  digestive  ferment  in  tin- 
ftetal  stomach  to  digest  all  the  albuminous  substances  of  the  li(iU(ir 
amnii  which  may  be  swallowed.  On  the  (luestion  of  the  nature  and 
source  of  the  contents  of  the  fcetal  stomach,  the  communication  of 
George  Iloliinson  {Month.  Journ.  Med.  Sc,  vii.  506, 1846-47),  although 
written  more  than  fifty  years  ago,  may  be  j)rofitably  studied. 

With  regard  to  the  activity  of  the  pancreas  in  ttetal  life,  there  is 
good  reason  to  believe  that  paucreatin,  the  fat-emulsifying  ferment,  is 
present  to  some  extent.  As  to  trypsin,  the  peptonising  ferment,  the 
evidence  is  not  so  clear ;  some  observers  have  found  it,  althongh  not 
in  all  cases,  while  others  have  not  noted  it  at  all  (c.i/.  Dolcris  and 
Butte).  The  third  or  diastatic  ferment  of  the  pancreas  does  not  seem 
to  be  present  either  at  birtli  or  earlier  in  antenatal  life.  Little  is 
known  regarding  the  intestinal  secretions  in  the  ffrtus ;  little,  that  is, 
that  is  in  any  degree  certain.  There  is  no  doulit  some  secreti(in  (jf 
succus  entericus,  but  what  its  composition  is  and  to  what  extent  the 
various  intestinal  glands  take  part  in  its  production,  must  remain  for 
the  present  obscure.  Some  reason  exists  for  supposing  that  the 
glands  of  Brunner  may  act  in  a  different  manner  in  the  foetus  as  com- 
pared with  the  adult.  But  speculation  can  serve  no  useful  end,  when 
so  little  is  known. 

Other  secretory  activities  in  the  f(ctus  are  found  in  the  seliaceous 
glands  and  in  the  serous  membranes.  The  vernix  caseosa.  with  which 
most  fa?tuses  are  covered  at  the  time  of  birth,  is  composed  prineipallj' 
of  sebum  from  the  skin  glands  and  of  desquamated  ei»idermic  scales ; 
possibly  the  epitriehium  may  contribute  to  its  formation.  It  contains 
from  78  to  84  j)er  cent,  water,  and  from  9  to  10  per  cent.  fats.  It  is 
doubtful  if  the  sudoriparous  glands  are  active  in  antenatal  life  :  if  they 
are,  their  activity  is  in  all  probability  restricted  to  the  tcrniiiial  weeks : 
the  purposes  which  these  glands  serve  in  the  adult  can  hardly  be  said 
to  exist  in  the  infant  before  birth.  The  manimar}'  glands,  however, 
are  functionally  active,  both  in  male  and  female  fcetuses,  as  is  demon- 
strated by  the  presence  in  them  of  a  milky  secretion  at  the  close  of 
intrauterine  existence;  the  glands  of  the  vagina  also  must  be  physio- 
logically operative,  fen-  I  have  often  had  occasion  to  note  the  large 
quantity  of  thick  white  mucus  lying  in  that  canal  in  female  foetuses. 
It  is  stated,  on  the  other  hand,  that  the  lachrymal  glands  do  not 
secrete  in  the  case  of  the  fo'tus  or  infant  at  birth.  The  activity  of  the 
serous  membranes  is  shown  by  the  presence  of  cerebro-spinal  fluid, 
and,  under  pathological  conditions,  by  the  occurrence  of  ascites,  hydro- 


i 


TH]-:  Fa-;Tra?4iiFCRjiii.-^6 


P:XCRETI0NS   of  the   FOiTUW^U^O^^^-^lQl 

thorax,  and  hydiMi-jjerieardiuni.  It  is  therefore  quite  clear  from  the 
evidence  of  the  secretions  that  not  a  little  independent  metaljolism  is 
carried  on  in  the  foetal  tissues ;  but  further  proof  is  forthcoming  from 
other  sources. 

Excretions  of  the  Foetus. 

The  foetus  has  excretory  as  well  as  secretory  activities.  The 
meconiimi  with  which  the  lower  part  of  the  intestine  is  distended  is 
made  up  of  swallowed  liquor  amnii,  lanugo  hairs,  vernix  caseosa,  and 
epidermic  squames,  of  bile,  mucus,  succus  entericus,  pancreatic  secre- 
tion, and  of  intestinal  shed  epithelium.  One  or  more  of  these  elements 
may  be  alisent :  when  the  bile  is  wanting,  as  in  congenital  obliteration 
of  tlie  bile  ducts,  there  is  found  the  so-called  meconiimi  amnioticum, 
which  is  of  a  yellowish  brown  or  even  of  a  grey  colour ;  when  there 
is  imperforation  of  the  oesophagus,  the  component  parts  which  are 
obtained  from  the  liquor  amnii  will  not  be  found.  Special  ovoid, 
yellowish  green  corj^uscles  (meconium  corpuscles)  have  been  descriljed. 
Chemical  analyses  show  that  the  meconium  contains  from  20  to  .30 
per  cent,  of  dried  solids,  which  consist  of  mucin,  biliverdin,  Ijilii-uljin, 
bile  acids,  cholesterin,  fats,  fatty  acids,  and  ashes  (chloride  of  jiotassium 
and  sodium,  phosphate  of  iron,  lime  and  magnesium,  and  sulphate  of 
lime  and  soda).  The  absence  of  peptones,  albumin,  leucin,  tjTosin, 
lecithin,  glucose,  lactic  acid,  and  lactates,  and  of  the  products  of  decom- 
position (indol,  phenol),  lias  been  noted.  According  to  B.  Moore 
(Schiifer's  Textbook  of  Fhi/siolor/y,  i.  474,  1898),  the  meconium  also 
contains  a  sulistance  giving  two  absorption  bauds,  one  to  the  red  side 
of  the  D  line,  and  the  other,  broader  and  darker,  l;>etween  the  D  and 
E  lines  of  the  spectrum.  Under  normal  circumstances  there  are  no 
micro-organisms  in  the  meconium  during  fffital  life,  and  I  have  taken 
meconium  from  the  rectum  of  a  still-born  infant  some  hours  after 
birth,  and  found  that  it  gave  no  growths  on  culture  media.  It  does 
not  appear  that  intestinal  peristalsis  can  be  very  active  in  antenatal 
life,  for  it  is  very  rare,  save  in  cases  of  intrauterine  asphyxia,  to  find 
that  any  meconium  has  been  voided  into  the  liquor  amnii ;  but  at  the 
same  time  it  is  necessary  to  bear  in  mind  that  the  researches  of  E. 
Eossa  (Arch./.  Gi/naek,  xlvi.  303,  1894)  go  to  prove  that  it  may  be 
imperative  to  revise  our  ideas  concerning  the  frequency  of  antenatal 
defecation  and  its  prognostic  significance  in  connection  with  foetal 
life.  Certainly  I  have  seen  the  membranes  and  cord  stained  green 
with  meconium  when  the  infant  was  born  alive,  and  when  apparently 
there  had  been  no  attempts  at  premature  respiration.  While  few 
writers  have  even  suggested  the  possibility,  of  the  occasional  pas- 
sage of  meconium  into  the  liquor  amnii,  many  have  strongly 
maintained  that  there  was  a  regular  emptying  of  the  contents  of 
the  bladder  during  foetal  life.  That  the  kidneys  may  excrete  a  fluid 
which  is  in  all  its  characters  urine,  cannot  in  the  present  state  of  our 
knowledge  Ije  doubted.  The  foetal  bladder  may  be  found  distended 
with  this  fluid  at  the  time  of  birth,  the  foetus  in  breech  presentations 
may  micturate  during  the  act    of  birth,  still-ljorn    and    premature 


162  ANTKNATAI,    I'ATHOLOdY   AND    HYCIKNK 

foetuses  may  show  on  ijnst-morlem  uxaiiiiiiitliou  ;i  Ijladilor  lull  of 
urine,  substances  (c.fj.  niethylene-blue)  given  to  the  mother  in  labour 
may  be  discovei'ed  in  the  urine  jiassed  by  the  new-born  infant,  and  in 
cases  of  valvular  obstruction  of  the  urethra  an  enormous  dilatation  of 
the  bladder  and  ureters  may  lie  met  with.  I  have  repeatedly  found 
lu-ine  in  the  bladder  of  still-born  fo'tuses,  lioth  mature  and  premature  ; 
and  recently  1  dissected  the  dead  but  fresh  fo'tus  of  a  woman  who 
died  from  eclampsia  and  jaun<lice  with  almost  entire  anuria — the 
fatal  bladder  was  over-distended  with  urine  ;  so  that  the  fictal  kidneys 
may  apparently  be  active  when  the  maternal  are  not.  From  all  these 
facts  it  is  clear  that  the  secretion  of  a  fluid  by  the  kidneys  in 
antenatal  life  takes  place.  That  the  fluid  is  urine  is  also  supported 
by  the  evidence  at  our  disposal.  It  is  true  that  it  is  very  pale  in 
colour,  that  it  is  very  watery,  and  that  its  specific  gravity  is  only 
1010  or  less  :  but  it  contains  urea  in  small  amount  (O'lo  per  cent, 
according  to  T.  A.  Helme,  Uri/.  Med.  Joarn.,  i.,  for  1893,  p.  1261), 
uric  acid  in  relatively  large  amount,  chlorides,  and  kreatiuin.  It  not 
infi-equently  contains  albumin,  a  fact  which  is  explained  by  C. 
Flensburg  {Nurd.  Med.  Ark.,  n.  ¥.,  iv.,  Hft.  2  and  3,  pp.  1-38,  1894)  as 
due  to  the  increase  in  the  uric  acid  ;  it  occasionallj'  contains  liiliruljin 
and  indican ;  and  it  may  contain  sul)stances  such  as  metbylene-blue 
administered  to  the  mother  (H.  Eeusing,  iTfecAr. /.  Gchurtdi.  a.  Llyniik., 
xxxiv.,  ]).  40,  1896).  The  giving  of  benzoate  of  soda  to  the  mother 
with  the  detection  of  hippuric  acid  in  the  urine  of  the  uew-ljorn 
(Gusserow's  experiment),  has  already  been  referred  to.  There  is 
therefore  no  room  left  for  doubt  that  the  foetal  kidneys  are  at  least 
occa.sionally  active  during  foetal  life ;  but  it  is  quite  reasonable  to 
suppose  that  their  activity  is  not  in  any  case  very  great  or  long-cou- 
tinued.  Like  several  other  functions  of  the  fcetus,  that  of  urine 
secretion  can  apparently  be  dispensed  with  if  the  placenta  continues 
to  act  in  a  normal  fashion  ;  but  there  is  the  provision  for  the  renal 
function  becoming  more  active  in  the  presence  of  placental  disability. 
With  regard  to  the  emptying  of  the  fcetal  bladder  into  tlie  liquor 
amuii,  there  seems  to  be  more  than  the  usual  difference  of  ojiinioii 
among  those  who  have  studied  the  iihysiology  of  antenatal  life.  There 
is  nothing  impossible  in  the  supposition  that  the  fwtus  occasionally 
micturates  into  the  liquor  amnii,  for  the  passage  of  urine  takes  pdace 
inmiediately  after  and  even  during  birth,  and  the  chemical  com- 
position of  the  liquor  amuii  and  of  the  faHal  urine  is  not  unlike  ;  but 
there  is  no  sufficient  evidence  that  this  happens  constantly  or  even 
often  during  intrauterine  existence,  and  in  normal  circumstances  it 
does  not  seem  probable  that  the  liquor  amuii  is  mainly  derived  from 
the  fcrtal  renal  secretion.  This  seems  to  be  a  fair  conclusion  to  draw 
from  the  experiments  of  L.  Schaller  {Ccntrlhl.  f.  Gyniik.,  xxii.,  321, 
1898)  ;  he  gave  to  the  pregnant  and  parturient  woman  phloridziu  (a 
glucoside  which  jimduces  glycosuria),  and  found  sugar  constantly  in 
the  urine  of  the  new-born  infant  and  very  rarely  in  the  liquor  anniii. 
With  regai'd  to  the  origin  of  the  licjuor  amnii,  when  that  fluid  is  in 
excess  (iiydramnios),  it  may  not  be  possible  to  speak  so  emphatically: 
the  occurrence  of  cardial-  and  renal  hyiiertrophy  in  the  twin  with  the 


1 


TRANSMISSION    FROM    FCETUS   TO   MOTHER  163 

hydramniotic  sac  (in  uniovular  twins)  suggests  a  possible  renal  origin 
of  some  of  the  amniotic  fluid  at  least  ( Vide,  F.  Schatz,  Physiologic  des 
Fotus,  Berlin,  1900  ;  P.  Strassmann,  Arch.  f.  Physiol.,  Sup2^lcment- 
Band,  218,  1899). 

I  have  thus  brought  forward  evidence  to  show  that  the  foetus  has 
excretory  as  well  as  secretory  activities,  and  have  instanced  the 
intestines  and  the  kidneys,  but  there  can  be  little  doubt  that  a  much 
more  important  and  more  constantly  active  excretory  organ  than 
either  of  these  exists  in  the  placenta.  The  reverse  current,  that  is  to 
say,  the  passage  of  substances,  soluble  and  even  formed,  from  the 
fffitus  to  the  mother  through  the  placenta,  has  been  practically 
established  by  experimental  and  clinical  evidence ;  theoretically, 
also,  it  seems  necessary  to  regard  the  placenta  as  the  great  ex- 
cretory organ  of  foetal  life.  Since  the  time  when  W.  S.  Savory 
{Lancet,  i.,  for  1858,  pp.  362,  385)  experimentally  induced  tetanus  in 
pregnant  cats  l)y  injecting  stryclanine  into  the  kittens  in  utero,  evi- 
dence has  been  gradually  and  on  the  whole  steadily  accumulating 
to  demonstrate  that  this  belief  is  well  founded.  Gusserow  (Arch.  f. 
Gynael:,  xiii.  56,  1878),  for  instance,  obtained  similar  results  to 
Savory ;  Preyer  {op.  cit.,  p.  219)  also  got  positive  evidence  from  the 
use  of  hydrocyanic  acid,  nicotine,  and  curare,  in  the  case  of  guinea- 
pigs  ;  and  it  has  been  shown  that,  in  asphyxia  of  the  mother  animal, 
the  blood  of  the  umbilical  vein  of  the  fretus  becomes  markedly  dark 
in  appearance,  indicating  that  oxygen  is  being  drawn  from  the  frotus 
to  the  maternal  organism.  Doubtless  carbonates  and  other  products 
of  normal  fretal  metabolism  pass  in  this  matripetal  current  through 
the  placenta,  although  it  is  difficult,  in  the  human  suliject  at  any  rate, 
to  get  direct  evidence  of  it.  It  has  been  suggested  that  in  eclampsia 
the  determining  factor  in  producing  the  convulsions  in  the  mother 
may  be  the  passage  of  toxines  from  the  foetus  into  her  circulation, 
and  in  support  of  this  Lannois  and  Brian  {Lyon  mid.,  Ixxxvii.  323, 
1898)  have  found  that  salicylate  of  soda,  iodide  of  potassium,  and 
methylene-blue  injected  into  the  foetus  may  be  detected  in  the 
maternal  tissues  and  urine.  Charrin  {Ann.  dc  gyni'c.  ct  d'ohst.,  L.,  p. 
197,  1898),  from  experiments  upon  the  passage  of  toxines  (of  diph- 
theria, of  the  Bacillus  pyocyaneiis),  has  come  to  the  conclusion  that 
such  substances  deposited  in  the  foetus,  either  directly  or  through  the 
spermatic  fluid  of  the  father,  can  be  transmitted  to  the  mother;  if 
they  do  not  pass  easily  or  in  great  quantity  tlirough  the  placenta,  a 
condition  of  maternal  immunisation  may  be  produced,  as  is  seen  in 
Colles'  law  in  syphilis.  It  is  interesting  to  note  that  a  similar  view 
was  held  by  A.  Harvey  as  long  ago  as  1848  {Month.  Journ.  Med.  Sc, 
ix.,  1130,  1818-49  ;  xi.,  299,  387,  1850  ;  Glasgow  Med.  Journ.,  vi.  385, 
1858-59),  although  without  the  scientific  proof  now  aflorded  by 
experimental  fcetal  pathology.  L.  Guinard  and  H.  Hochwelker 
{■Journ.  de  physiol.  et  de  path,  ghi.,  i.  456,  1899)  have  experimentally 
shown  that  rose  aniline  trisulphonate  of  soda  passes  easily  from  fcetus 
to  mother,  and  can  be  found  in  the  maternal  urine  and  even  in  the 
blood  ;  if,  however,  the  fcetus  be  killed  (as  by  strophanthus)  and  the 
fcEto-maternal  circulation  stopped,  it  does   not    pass,  and  it  is  only 


104  ANTENATAI.    I'ATHOLOCiY    AND    HYCIIEN'R 

f(iU!iil  ill  tlie  fii'tal  liswiu'S  :  the  dealli  nf  the  firtiis,  llierefore,  suspends 
the  fu'to-iilaceiital  iiiterehaniies. 

Friiiu  all  that  lias  l)een  stated,  it  may,  I  think,  be  safely  conchuleil 
that,  both  on  account  of  its  secretory  and  its  excretory  processes,  the 
foetus  must  be  regarded  as  the  sphere  of  very  considerable  nietal)olic 
activity.  Before,  however,  I  leave  this  aspect  of  the  jihysiology  of 
the  fcctus,  it  may  be  well  to  refer  to  the  question  of  the  jiart  played  in 
antenatal  vital  processes  by  the  thymus,  thyroid,  and  suprarenal 
glands,  and  liy  the  pituitary  body.  Tliis  is  an  obscure  corner  of  an 
obscure  department ;  but  we  can  at  least  benefit  by  realising  how 
obscure,  for  we  may  thereby  lie  stimulated  to  endea\'our  to  throw 
some  illumination  upon  it. 


Function    of  the    Foetal   Thymus,   Thyroid,    Adrenal   and 
Pituitary   Glands. 

The  possible  htematopoietic  function  of  the  thymus  as  the  parent 
source  of  the  white  blood  corpuscles,  has  been  already  alluded  to,  but 
it  may  perform  other  functions  diu-ing  antenatal  life  and  in  the  early 
part  of  childhood.  According  to  H.  Ifoger  and  C.  Ghika  {Journ.  de 
2}hysiol.  ct  depath.gcn.,  ii.  712, 1900),  the  epithelial  ])art  of  the  thymus 
has  entirely  disappeared  at  the  third  month  of  intrauterine  life,  and 
its  structure  is  clearly  lymphoid ;  there  are  no  concentric  corpuscles 
of  Hassall  to  be  seen  at  this  time,  so  that  it  is  probable  that  they  are 
not  derived  from  the  primitive  epithelial  portion  of  the  gland. 
After  the  si.xth  month,  at  which  date  there  is  a  marked  increase 
in  weight  of  the  thymus,  the  corpuscles  are  ([uite  easily  seen.  The 
structure  of  the  organ  becomes  more  complicated  in  the  presence  of 
infective  agencies,  so  that  it  ]iossil)ly  plays  a  part  in  the  defence  of 
tlie  organism  ;  but  whether  it  does  so  or  not  before  birth  must  be 
regarded  as  uncertain.  It  is  stated  by  K.  Svehla  (ArcJi.  f.i'.rpcr.  Path, 
u.  Pharm.,  xliii.  321,  1900)  that  the  thymus  of  the  human  foetus 
does  not  contain  the  active  ingredient  (which  lowers  the  lilood 
pressure  and  (quickens  the  pulse)  that  forms  after  birth.  Another 
interesting  and  perhaps  suggestive  fact  has  been  brought  out  by  the 
investigations  of  Katz  {Proyris  med.,  3  s.,  xi.,  p.  385,  1900),  and  by 
Bourneville  {ibid.,  p.  389),  wlio  have  found  that  the  thymus  atro]ihies 
and  disappears  earlier  after  birth  in  infants  with  little  or  no  in- 
tellectual development.  This  mav  l)e  taken  in  conjunction  with  tlie 
belief  of  G.  Gauthicr  (Pn:  dc  wed.,  xx.,  pp.  :19,  225,  410,  1900)  tliat 
tiie  sole  function  of  the  thymus  is  to  act  as  a  regulator  of  growth 
in  the  early  part  of  life.  As  a  matter  of  fact,  the  antenatal  as 
well  as  the  postnatal  function  or  functions  of  the  thymus  are 
at  present  unknown.  I  have,  however,  lieen  struck  by  the  extra- 
ordinary frequency  with  which  I  have  met  with  a  normal 
thymus  ill  fictuses  with  various  malformations  and  teratolngical 
states. 

The  tlnjroid  (ilaiid  is  a  n-iiiarkaMc  liudy,aiid  the  part  it  lias  ]]laycd 
in  the  history  of  I'hysiology  is  also  remarkable.     After  having  lieen 


i' 


FUNCTIONS   OF  THYROID  IGo 

for  years  regarded  as  a  couiparatively  uiiimpdrtaiit  organ,  as  at  iimst 
a  haematopoietic  organ  of  not  the  first  rank,  it  has  recently  come  to 
take  a  high  and  honourable  place  among  the  most  important 
structm'es  of  the  body.  The  thyroid  along  with  the  parathyroids, 
which  are  the  link  binding  it  to  the  thymus,  is  now  known  to  be  tlie 
great  regulator  of  body  metabolism,  and  to  be  essential  for  growth  in 
at  any  rate  the  early  years  of  life ;  defects  in  it  are  the  causes  of 
disease,  and  there  is  a  thyroid  theory  of  cretinism,  of  exophthalmic 
goitre,  of  obesity,  of  infantilism,  and  of  various  skin  diseases,  besides 
suggestions  that  the  thyroid  may  be  at  least  one  of  the  causes  of 
eclampsia  (in  jDregnancj'),  of  adenoids,  and  of  haemophilia.  After 
birth,  at  any  rate,  the  thyroid  has  an  internal  secretion  (iodo-thyrin), 
which  may  he  described  as  exercising  an  antitoxic,  or,  better,  a 
medicinal  effect  upon  the  toxic  or  pathological  products  of  proteid 
metabolism  :  these  toxic  principles  are  neutralised  and  stored  up  as 
colloid  or  thyro-proteid  in  the  thyroid  gland.  Possibly  the  iodine  in 
the  iodo-thyrin  has  the  most  important  action  in  maintaining  the 
nutritive  equilibrium  ;  possibly,  also,  the  parathyroids  have  a  func- 
tional association  with  the  thyroid  in  preparing  the  iodine  for  the 
iodo-thyrin.  Diminished  thyroid  activity  leads  to  slowing  of  the 
nutritive  processes,  while  increased  leads  to  undue  rapidity  of  metabolic 
changes ;  both  these  conditions  may  exist  as  purely  fvmctional  states 
— hypothyroidism  and  hyperthyroidism.  There  is  a  great  deal  of 
investigation  yet  to  be  imdertaken  before  we  shall  know  all  the 
relations  which  exist  between  normal  and  aljnormal  thyroid  activity 
and  the  pregnant  state.  The  physiological  hypertrojahy  of  the  thyroid 
of  the  pregnant  woman  was  not  unknown  both  to  the  medical 
profession  and  to  the  laity  of  past  ages  ;  and  no  doubt  it  plays  a  part 
in  safely  carrying  on  the  wonderful  and  exacting  series  of  nutritive 
and  developmental  changes  which  tests  the  maternal  organism  to  its 
utmost  limits  (M.  Lange,  Ztschr.  f.  Gcburtsh.  u.  Gyndk.,  xl.,  p.  34, 1899). 
It  is  also  known  that  there  is  thyroid  hypertroph}'  at  the  time  of 
commencing  puberty,  that  ovulation  is  accompanied  by  hyper;emia  of 
the  thyroid,  and  that  the  thyroid  is  active  during  lactation.  Fiu'ther, 
it  is  supposed  that  the  vomiting  of  pregnancy,  and  possibly  the  thin- 
ness of  the  face  which  then  often  is  noticealjle,  are  due  to  increased 
secretion  from  this  gland.  It  is  surmi.sed,  also,  that  the  marked  flow 
of  the  milk  about  the  third  day  of  the  puerperiuin  is  due  to  the 
sudden  increase  of  thyroid  secretion  in  the  maternal  blood  caused  l)y 
the  birth  of  the  foetus.  This  statement  Ijrings  us  then  to  the  diffi- 
cult question  of  the  function  of  the  fcetal  thyroid.  Has  the  thyroid 
gland  of  the  unborn  infant  the  same  regulating  function  in  connection 
with  the  metabolism  of  antenatal  life  as  the  thyroid  of  the  mother  has 
over  the  metaliolism  of  the  adult  body,  or  as  the  thyroid  of  the  infant 
has  over  the  metabolism  of  infancy  and  childhood  ?  Has  the  maternal 
thyroid  in  pregnancy  the  double  function  of  regulating  both  the 
maternal  and  the  ftetal  metabolic  processes  ?  When  the  thyroid  of 
the  one  is  defective,  can  the  thyroid  of  the  other  supplement  it  ? 
These  and  a  great  many  other  questions  cannot  in  the  present  state 
of  our  knowledge  lie  satisfactorily  answered ;  but  some   things  arc 


16U  ANTKN'ATAL    I'A'IHOI.OdV    AND    HYGIENE 

]iiiit.ly  kuowu  and  others  have  l)eeii  surmised :  and  to  tliese  we  may 
l)rieHy  refer,  always  keei)ing  in  mind  tlie  imperfect  nature  of  our 
aci[uaintance  with  these  problems.  In  tiie  first  ])lace,  it  is  supposed 
that  the  secretion  of  tlie  thyroid  cannot  c(jntain  iodine,  for  that 
element  is  not  to  be  found  in  the  fVctus ;  and  if  the  iodine  be  c)f  great 
functional  use,  tiieu  the  ftetus  must  he  dei)endent  for  it  ujwn  the 
maternal  and  not  upon  its  own  thyroid.  The  goitrous  cretin  is  bom, 
it  i,s  surmised,  with  a  healthy  thyroid,  but  through  absence  of  iodine 
in  his  environment  the  thyroid  degenerates  some  time  after  birth  ;  it 
would  be  interesting  to  know  exactly  the  state  of  the  thyroid  in  the 
oHs]iring  of  goitrous  parents.  In  the  fietal  thyroid  from  the  third 
month  onwards  there  is  found  a  colloid  material  called  thyro- 
niucoin  ;  the  reappearance  of  this  substance  in  later  life  is  regarded 
as  the  cause  of  exophthalmic  goitre  ;  as  Gauthier  {Jirv.  de  tni'il.,  xx., 
pp.  39,  225,  410,  1900)  expresses  it,  this  substance  in  the  adult  plays 
tiie  part  of  a  noxious  material,  for  it  is  "utilisable  seulement  dans 
nil  organisme  fcctal  ou  tout  est  ii  crcer,  a  transformer  et  a  dctruire." 
With  regard  to  experiments  upon  animals,  it  has  been  stated  that 
the  removal  of  the  thyroid  in  a  pregnant  animal  will  cause  the  birtli 
of  a  fietus  with  rickets  (Gauthier).  Further,  it  has  lieeu  found 
experimentally  that  in  cases  where  the  thyroid  of  the  l)itch  was  in 
part  removed,  the  ftetal  puppy  showed  a  hypertrophied  thyroid  con- 
taining no  colloid.  W.  Edmunds  {Brit.  Med.  Jonrn.,  i.,  for  1900, 
J).  1341)  removed  the  lobe  of  the  thyroid  and  the  parathyroids  on  one 
side,  and  on  the  other  nearly  the  whole  of  the  lobe,  but  left  one  para- 
thyroid ;  about  four  months  later  the  animal  (a  latch)  gave  birth  to  a 
puppy  whose  thyroid  showed  absence  of  colloid  and  a  hyjiertrophic 
state,  which  was  regarded  as  compensatory  to  the  maternal  defect. 
K.  Svehla  (lov.  cit.)  found  for  the  thyroid  as  for  the  thymus,  that  in 
the  human  fcetus  the  gland  did  not  contain  the  material  thatiiuickens 
the  pulse  rate  and  lowers  the  blood  pressure.  From  this  confused 
mass  of  facts  and  si^eculations  it  can  only  at  present  be  gathered,  that 
it  is  improliable  that  the  thyroid  during  ftetal  life  acts  in  the  same 
way  or  in  the  same  degree  as  it  begins  to  do  after  birth :  the  maternal 
thyroid  may  have  to  secrete  iodo-thyrin  for  both  tlie  maternal  and 
foetal  organism  ;  but  it  is  possible  that  in  cases  of  maternal  thyi-oidal 
defect  the  fietal  gland  may  to  some  extent  take  on  its  postnatal 
function  ;  and  these  conclusions  do  not  necessarily  mean  that  the 
thyroid  is  not  acti\'e  in  intrauterine  life,  but  only  that  it  is  not  active 
in  the  same  way  as  after  birth.  Further,  Svehla 's  obsei'vations  and 
experiments  seem  to  show  that  the  thyroid  of  the  fietus  of  the  cow 
possesses  this  power  over  the  circulation  licfore  birth,  which,  as  has 
been  stated,  that  of  the  human  fictus  does  not. 

Along  with  the  thymus  and  the  thyroid  glands,  it  is  convenient  and 
ajipropriate  to  refer  to  the  suprarenal  capsulc't  of  the  foetus.  There 
is  a  hypertrophy  of  the  maternal  suprarenal  capsules  in  pregnancy, 
and  in  the  foetus  these  organs  are,  as  is  well  known,  relatively  large 
in  size;  but  the  exact  meaning,  or  even  an  approximation  to  the 
meaning,  of  these  conditions  is  not  forthcoming.  In  the  adult  the 
efi'ect  of  the  internal  secretion   of   the    suprarenal   capsules   would 


GROWTH   OF   FffiTUS  167 

appear  to  be  to  raise  the  blood  pressure,  ami  to  slow  the  heart  or  to 
quicken  it  if  the  vagi  be  cut.  There  is,  therefore,  a  degree  of  physio- 
logical antagonism  between  the  thymus  and  thyroid  and  the  supra- 
renal capsules ;  and  it  is  interesting  that  in  pregnancy  all  the  three 
are  large, — the  thyroid  and  suprarenals  in  the  mother,  and  the 
thymus  and  suprarenals  in  the  fcetus.  ^At  the  same  time,  it  seems 
to  be  clear  from  the  experiments  of  iSvehla  {loc.  cit.)  and  others 
that  the  adrenals  in  the  human  fcEtus  do  not  contain  the  vaso- 
constrictor principle,  although  those  of  the  foetal  calf  apparently 
do.     Why  there  should  be  this  difierence  is  not  in  any  measure  clear. 

The  effects  of  functional  activity  of  the  pituitary  body  in  the 
foetus  are  not  yet  known.  In  the  adolescent  and  adult  it  appears  to 
control  the  growth  of  the  body,  and  possibly  does  in  later  life  what 
the  thymus  and  thyroid  do  in  earlier  postnatal  life.  Lesions  of  the 
pituitary  appai'ently  cause  acromegaly,  which  is  a  form  of  gigantism  of 
the  adult.  It  has  been  thought  that  the  thyroid  and  pituitary  may 
supplement  each  other  in  their  physiological  effects,  and  that  the 
pituitary  may  take  on  a  vicaiious  action,  for  enlargement  of  the 
pituitary  has  been  noticed  after  thyroidectomy ;  but  experiments 
seem  rather  to  show  that  the  internal  secretion  of  the  pituitary  has 
an  action  more  allied  to  that  of  the  supi-arenal  glands.  At  any  rate, 
extracts  of  the  hypophysis  increase  the  force  of  the  heart's  beat  and 
raise  the  blood  pressure.  As  has  Ijeen  said,  nothing  is  known  aliout 
the  action  of  the  pituitary  before  birth  ;  but  it  is  interesting  to  note 
tliat,  while  some  ascribe  acromegaly  to  a  continuance  of  the  antenatal 
function  of  the  gland  in  postnatal  life,  others  (M.  Collina,  Arch.  ital. 
de  hioL,  xxxii.,  1,  1899)  find  the  cause  in  a  perversion  of  its  function, 
toxic  sul)stances  increasing  and  setting  up  irritation  in  the  tissues  of 
the  limbs.  That  is  to  say,  some  consider  that  the  pituitary  secretion 
does  good  during  foetal  life,  l5ut  harm  if  it  continue  to  be  poured 
out  later ;  while  others  think  that  it  must  be  altered  after  birth  in 
order  that  it  may  produce  a  pathological  effect.  About  all  the 
internal  secretions  of  the  fcetus,  it  is  permissible  to  suppose  that 
they  have  a  different  action  in  antenatal  as  compared  with  postnatal 
life ;  but  it  is  simply  a  supposition. 

From  what  has  been  said  regarding  the  intracorporeal  metabolism 
of  the  fcetus,  it  must  have  become  abundantly  clear  to  the  reader  that 
the  problems  which  have  been  touched  upon  have  taxed,  and  will  yet 
tax,  the  best  efforts  of  the  most  skilled  physiologists  for  some  time 
to  come. 

Growth  of  the  Fcetus. 

If  the  complexity  of  the  problem  of  fa^tal  nutrition  has  been 
fully  appreciated,  it  will  be  evident  that  it  can  be  no  easy  task  to 
determine  what  conditions  favour  and  what  hinder  the  growth  of 
the  unborn  infant.  Nevertheless  some  writers  have  attempted  to 
settle  these  points  by  very  simple  means,  and  have  almost  of  neces- 
sity failed.  It  is  a  matter  of  everyday  experience  that  new-born 
infants  differ  markedly  from  each  other  in  size  and  weight,  even 
when  there  is  good  reason  to  Ijelieve  that  they  have  been  liorn  at 


1G8  ANTJ'.NATAI.    PATHOLOGY    AND    HYdlKNE 

the  full   term  of  antenatal   life,  and  even  when  the  niotliers  have 
enjoyed  uniformly  good  health.     It  has  not  yet  )ieen  found  ])os.sible 
t<i  predict  even  approximately  what  the  lengtli  and  weight  of  the 
infant  will  he,  and  althougli  attempts  have  been  made  to  regulate 
the  growth  of  the  fietus  l)y  controlling  the  diet  of  the  mother,  they 
have  not  met  with  conspicuous  success.     The  factors  of  fietal  nutri- 
tion are  so  numerous,  and  their  relations  are  so  intricate,  that  it  is 
impossible   to   arrive   at   the  coefficient   of   mitrition,  so  to  speak. 
Many  writers,  however,  have  worked  at  this  problem.     While  some 
have  held  tliat  the  doveloi)m(>nt  of  the  ftetus  depends  upon  the  age 
(if  the  mother,  her  parity,  the  duration  of  lier  menstrual  How,  and 
the  date  of  the  commencement  of  her  reproductive  life,  others  have 
seen  a  connection  between  the  size  of  the  infant  and  its  sex,  the 
length  of  its  cord,  and  the  amount  of  its  liquor  amnii.     Now,  some 
of  these  factors  {e.g.  the  age  of  the  mother  and  the  sex  of  the  foetus) 
apparently  have  some  intluence  upon  antenatal  growth,  althougli  it 
is  often  clear,  in  the  light  of  the  knowledge  of  fa^tal  physiological 
problems  which  we  now  possess,  that  the  reasons  gi\'en  for  a  belief 
in  the  efficiency  of  the  factors  are  (juite  inadmissible.     But  the  chain 
of  factors  which  controls  the  rate  of  foetal  nutritive  processes  is  too 
long  to  make  it  easily  possible  to  pick  out  the  separate  links  and 
assign  to  each  of  them  their  relative  importance.     Among  the  pos- 
sible factors  may   be  named :    the  health   of  the  mother,  her  food 
supply  (although   it  must  not  be  concluded  that  a  starved  mother 
will  give  birth  to  a  puny  infant),  her  employment  (for  there  is  some 
reason  to  suppose  that  if  the  pregnant  woman  can  rest  in  the  last 
montlis   iif  gestation   the   weight   of  her  offs])ring  will    lie    greater, 
liacliinKint,   Thi^c.  dc  Pari^i,  1898),  the  structural  and  ]>hysiological 
integrity  of  the  placenta,  the  activity  of  the  fcetal  organs  of  assimila- 
tion, and  the  state  of  the  growth-dominating  glands  lioth  in  mother 
and  fwtus.     Furthermore,  even  if  these   factors  were  known,  tliere 
remains  the  unknown,  and  almost  unknowable,  intluence  wliich  the 
fietus  brings  with  it  from  its  embryonic  and  germinal  life  into  its 
foetal  existence — I  mean  the  hereditary  tendency  to  grow  into  a  large 
or  a  small  infant.     F.  La  Torre  {Nouv.  arch,  d'obst.  ct  dc  gynt'c,  iii., 
l)p.  138,  185,  etc.,  1888),  in  his  articles  on  this  problem — "ce  nteud 
gordien,"  as  he  justly  calls  it — appreciated  to  some  extent  this  diffi- 
culty, for  he  abandoned  such  factors  as  the  menstrual  history  and 
state  of  parity  of  the  mother,  and  gave  great  value  to  the  state  of 
health  of  tlie  fatlier,  "  le  facteur  ]icre."     In  apjiealing  to  this  factor, 
lie  admitted  that  tlie  size  to  lie  attained  by  the  fo-tus  was  to  a  large 
extent   determined    before    the   commencement    of    truly    fcetal    life 
(second  month   of   antenatal  existence).      Tiiis  intluence,  certainly, 
cannot  be  neglected ;    neither  can  the  state  of  the  mother  before 
jiregnancy  and  her  heredity  be  left  out  of  accomit.     Further  discus- 
sion of  this  Ciordiau  knot  of  a  problem  is  not  in  the  ])resent  state 
of    our    knowledge    ]irofitable.      To  have   recognised   tlie   difficulties 
whicli  surround   it,  is,  however,  not  willmut  sduie  small   degree   of 
profit.     We  know  that  it  is  a  CJordian  knot,  and  tliat  we  have  not 
even  the  means  nf  cutting  it,  far  less  of  untying  it. 


MOVEMENTS   OF   FCETUS  1C9 


Movements  of  the  FcEtus. 


From  the  time,  usually  aljout  the  mid-tenn  of  pregnancy,  when 
the  mother  feels  "  life  "  or  "  quickening,"  until  the  birth  of  the  infant, 
there  is  no  room  for  doulit  that  the  fa-tus  is  capable  of  moving  in  the 
liquor  aninii.  Women  rely  upon  the  occurrence  of  these  "  move- 
ments "  to  enalile  them  to  confirm  the  diagnosis  of  pregnancy  which 
was  provisionally  made  when  the  menses  ceased  and  the  morning 
sickness  began  ;  the  "  stirrage  "  also  brings  to  the  maternal  mind  the 
welcome  intelligence  that  the  infant  is  alive  and  not  dead  in  the 
womb.  But  there  is  aljundant  evidence,  Ijoth  from  the  experiments 
upon  the  lower  animals  and  from  the  examination  of  abortions,  that 
the  foetus  moves  before  the  mid-term  of  antenatal  life ;  in  fact,  it 
may  be  reasonably  concluded  that  during  the  whole  of  foetal  exist- 
ence and  even  in  the  neo-foetal  period  fcetal  movements  occur.  I 
have  seen  rigor  mortis  in  a  five  months  foetus  (80),  and  J.  Tissot 
{Arch,  de  2>liysiol.  norm,  et  2Mth;  5  s.,  vi.  860,  1894)  has  seen  it 
coustantlj'  in  fwtal  kittens  dying  in  utero ;  and  in  these  and  similar 
observations  we  Hnd  evidence  of  an  indirect  kind  as  to  the  occurrence 
of  muscular  movements  before  birth.  Doubtless  antenatal  muscular 
action  is  neither  so  powerful  nor  so  prolonged  as  postnatal  (and  the 
cadaveric  rigidity  is  not  so  intense),  but  it  is  capable  of  being  lirought 
into  action,  and  it  is  brought  into  action  probably  from  the  sixth 
week  onwards. 

Foetal  movements  are  independent  of  the  supply  of  oxygen,  and, 
what  is  still  more  surprising,  they  appear  to  be  independent  also  of 
the  cerelirum  and  medulla,  for  they  occur  in  anencephalic  and  even 
in  acephalic  fu?tuses,  and  may  persist  after  craniotomy.  For  the 
postnatal  activity  of  the  respiratory  muscles,  however,  the  medulla 
oblongata  is  necessary,  as  was  well  shown  in  the  case  of  anencephaly 
reported  by  Onodi  (Monatschr. /.  Geburtsh.  u.  Gynaek.,x\.  718,  1900), 
in  which  the  monstrous  foetus  survived  birth  for  two  days  and 
breathed,  the  medulla  and  pons  being  present,  although  the  cerebrum 
and  cerebellum  were  absent.  This  independence  of  the  nervous 
centres  was,  it  will  l^e  remembered,  manifested  also  by  the  muscular 
activit}'  of  the  fcetal  heart  {vide  Chapter  IX.). 

Several  varieties  of  foetal  movements  can  be  recognised  both  by 
the  obstetrician  and  by  the  mother :  there  are  the  movements  of 
revolution  or  rotation,  by  which  the  foetus  changes  his  position  or 
presentation ;  there  are  the  extensions  of  the  limbs  and  spine,  by 
which  there  is  a  temporary  loss  of  the  typical  foetal  attitude  of 
flexion ;  and  there  are  the  rhythmical,  heaving  movements  which 
have  been  ascriljed  to  the  diaphragm  and  intercostal  muscles  of 
the  unborn  infant,  and  which  have  been  compared  to  swallowing 
movements,  to  hiccough  (foetal  singultus),  or  to  intrauterine  re- 
spiration. As  has  already  been  stated,  Pestalozza  {loc.  cit.)  and 
Ferroni  {loc.  cit.)  have  specially  investigated  the  last-named  move- 
ments and  have  obtained  graphic  representations  of  them.  From 
another  standpoint,  fretal  movements  may  be  subdivided  into  passive, 


170  ANTRNATAI.    I'ATHOI.OCJY    AND    HYGIENE 

irritative,  retiex,  iiii]mlsive,  and  instinctive;  this  is  tlie  suggestive 
classification  adopteil  by  Preyer  (o]i.  rit.),  but  ratlier  from  the  study 
of  the  muscular  manifestations  of  the  new-lioru  than  of  the  unborn 
infant,  so  it  niay  l)e  concluded.  The  passive  movements  of  the  human 
fcetus  are  chieHy  <if  importance  as  aM'ording  to  the  ol)stetrician  the 
valuable  sign  of  pregnancy  known  as  ballottement.  Of  the  irritat- 
I  ive  movements  little  is  known,  save  that  they  are  sometimes  excited 
^by  poisons  circulating  in  the  mother's  blood.  The  reilex  movements 
are  very  prominent  in  the  new-born  infant,  and  are  probably  well 
marked  also  before  l)irth  (Fiuizio,  Pcdmtria,  viii.  2'A,  1900);  the 
tickling  of  the  palms  or  soles  causes  flexion  of  the  digits  after  the 
infant  is  born,  and  possibly  the  pressure  of  the  uterine  walls  or  of  the 
other  foetal  parts  may  produce  similar  results  in  utero.  The  im- 
pulsive movements  have  been  compared  by  Preyer  to  those  of  half- 
awakened  hibernating  animals,  and  are  neither  reflex  nor  instinctive ; 
they  are  not  caused  by  peripheral  stimulation  nor  by  cerebral  initia- 
tion;  jiurposeless  movements  of  the  limbs  are  instances  of  them. 
Amijng  the  instinctive  movements  which  probabh*  the  fcetus  is 
capable  of  making,  are  sucking  and  swallowing.  Little  is  known 
regarding  the  stimuli  which  excite  foetal  movements.     Laying  a  cold 

I  hand  upon  the  maternal  aljdomen  nearly  always  does  so,  a  fact  which 
the  obstetrician  makes  use  of  in  difficult  cases  of  diagnosis.  So  ap- 
parently does  a  cold  drink  ;  and  indeed  any  shock  or  jar  to  the  maternal 
system  may  act  as  an  excitant.  Ch.  Fere  {Sensation  ct  hkhh-i- 
mcnt,  p.  94,  Paris,  1900)  has  gathered  together  some  other  excitunis 
or  supposed  excitants  of  foetal  movements.  They  are  loud  siaimls 
and  strong  smells,  tlie  red  rays  of  light  (as  in  the  case  of  a  hysterical 
pregnant  woman  in  a  photographic  saloon),  maternal  emotions  (anger, 
fear),  and  dreams,  fatigue,  and  hunger.  It  has  been  noted  that  one 
of  the  difficulties  in  obtaining  a  skiagram  of  the  fcetus  in  utero  is 
the  liability  of  the  unl)orn  infant  to  be  thrown  into  violent  move- 
ments )jy  the  Piontgen  rays  (Bouchacourt,  L'Ohstetrique,  v.,  y\\.  L'd. 
l:>7,  1900).  It  is  proljable  that  various  medicines  taken  liy  the 
mother  influence  the  frequency  and  force  of  the  movements  of  the 
unliorn  infant;  and  it  has  Ijeen  noticed  that  in  women  who  have  lieen 
in  the  habit  of  taking  morphia,  abstinence  from  that  drug  has  led  to 
spasmodic  activity  of  the  foetus  in  the  uterus.  Fere  {loc.  cit.)  regards 
all  foetal  movements  as  reflex  in  character ;  the  various  excitants  all 
lead  directly  or  indirectly  to  uterine  contractions,  and  these,  b}- 
compressing  the  foetus,  produce  the  muscular  activity. 

Sensation  in  the  Foetus. 

There  can  be  no  doubt  that  the  fcetus  possesses  cutaneous 
sensiliility  before  birth,  and  that  pinching  the  skin  of  the  limbs  and 
other  parts  sets  up  reflex  movements ;  but  that  there  is  sensibility 
to  temperature  is  doubtful,  at  least  the  liquor  amnii  ])revents 
sudden  changes  in  the  heat  of  tlie  surrounding  iwrts,  and  so  interferes 
with  the  testing  of  this  part  of  tiie  nervous  system.  There  may  lie 
some  sensation  of  taste  before  birtli :  but  it  is  difficult  to  imagine  tlie 


SENSATION    IN  THE   FCETUS  171 

existence  of  any  degree  of  hearing,  sight,  or  smell.  At  tiie  same  time 
the  faculty  of  perceiving  smells  and  sounds  exists  before  birth,  and 
is  manifest  in  prematurely  born  infants ;  and  the  retina  is  sensitive 
to  light  and  the  pupil  reacts  to  mydriatics  and  myotics  at  the  time 
when  the  infant,  premature  or  mature,  is  expelled  from  the  womb. 
Fere  {loc.  cit.)  points  out  that  the  maternal  sensations  of  sight, 
hearing,  smell,  and  taste  are,  as  it  were,  reduced  for  the  foetus 
to  the  common  elementary  form  of  movement.  All  that  need  be  said, 
all  that  can  be  said,  about  mental  processes  in  the  unborn  infant  is 
that  there  is  much  sleep. 

The  attempt  has  been  made  in  the  preceding  pages  to  give  the 
reader  some  idea  of  what  is  known  of  the  physiology  of  the  foetus, 
for  upon  it  must  be  built  up  our  views  of  the  hygiene  of  antenatal 
life,  and  upon  it  must  be  founded  the  explanation  of  the  peculiarities 
of  fcetal  maladies.  How  defective  our  knowledge  is,  will  have  l^een 
very  apparent ;  but  there  is  at  least  one  hopeful  eircunastance  to 
record — the  number  of  earnest  attempts  that  are  every  day  being 
made  to  supply  the  defects  and  to  increase  the  sum  total  of  what  is 
surely  known  of  vital  processes  in  the  infant  still  within  the  uterus, 
but  already  evincing  a  degree  of  independence  in  its  life. 


CHAPTER    XI 

r<ptal  Pathology  :  General  Principles.  Scope  of  Fuftal  Pathology  ;  Causes  nf 
Limited  Knowledge  ;  FcL'tal  Morbid  States ;  Classification  :  Causes  of 
Pecviliarities  of  Ffotal  Diseases — (1)  Influence  of  Intrauterine  Environ- 
ment ;  (2)  The  Placental  Factor  ;  (3)  The  Emljryonic  Factor. 

The  fatal  period  of  life  is,  as  I  have  been  trying  to  make  eleav,  lull 
of  wonders.  There  is  the  wonder  of  its  anatomy,  as  revealed  by  tiie 
study  of  the  mechanism,  which  shows  sucli  accurate  adaptation  to 
the  varying  needs  of  the  various  months  of  antenatal  life.  There  is 
the  wonder  of  its  physiology,  the  marvel  of  the  mechanism  in  action, 
with  all  its  minor  wonders  of  foetal  circulation,  respiration,  nutrition, 
e.Kcretion,  motion,  and  sensation.  There  is  the  mystery  of  the  inter- 
relation with  semi-independence  of  the  maternal  and  fojtal  economies, 
the  intertwining  of  two  lives.  There  is  the  transition  of  birth,  accom- 
plished as  a  rule  so  smoothly  and  yet  so  complicated,  so  profound — 
truly  a  wonder  among  wonders.  There  is  the  no  less  wonderful  but 
less  evident  transition  from  the  embryonic  to  the  fcetal  state.  Truly, 
Nature  is  a  past-mistress  in  the  art  of  making  transitions  easy  and 
of  utilising  the  materials  and  forces  of  one  economy  for  the  construc- 
tion and  working  of  another ;  her  secret,  if  we  may  guess  it,  is  that 
she  makes  careful  preparations  long  before  the  transition  actually 
happens,  and  so  tlie  process  is  ipiick,  safe,  and  smooth. 

We  are  now  in  a  position  to  study,  with  some  hope  of  under- 
standing its  intricacies,  the  foetal  mechanism  thrown  into  disordered 
action  or  thrown  out  of  action  fdtogether — I  refer  to  firtal  diseases 
and  intrauterine  death.  Here,  also,  we  shall  find  much  to  marvel 
at — the  safeguards  with  which  Nature  has  surrounded  the  delicate 
foetus  in  utero,  the  protection  of  the  fa^tal  against  the  diseased 
maternal  organism  and  of  the  maternal  against  the  diseased  or  dead 
fo-tal  organism,  the  tendency  to  ra]iid  rejiair  or  recovery,  and 
the  interesting  peculiarities  of  morbid  processes  occurring  in  im- 
mature structures.  In  this  chapter  fall  to  be  considered  the  general 
principles  which  seem  to  me  to  govern  the  manifestations  of  disease 
in  the  fcetus,  and  to  account  for  the  characters  which  antenatal 
maladies  possess.  ]5ut,  first,  what  ai'c  the  morbid  states  of  tlie 
fcptus  ? 

Scope  of  Foetal  Pathology. 

Fu'tal  pathology  is  cliafacterised  liy  diseases  as  distinguished  from 
embryonic  jiatlmlogy,  wliich  has  malfdrmations  and  monstiosities  as 


GENERAL   PRINCIPLES  173 

its  peculiar  possession.  If  the  ([uestion  be  asked,  "  "What  are  the 
diseases  to  which  the  foetus  is  liable  ?  "  the  reply  must  be  that  with 
some  inconsiderable  exceptions  it  is  liable  to  all  the  diseases  to  which 
later  life  is  liable.  I  made  the  discovery  of  the  wide  scope  of  ftetal 
pathology  some  years  ago,  when  engaged  in  writing  my  work, 
The  Diseases  of  the  Feetus  (2,  -4) ;  I  found  that  in  two  volumes  (the 
only  ones  which  have  been  published)  I  was  able  to  discuss  fully 
no  more  than  the  congenital  diseases  of  the  subcutaneous  tissue 
and  some  of  those  of  the  skin  ;  and  it  soon  became  clear  to  me  that 
I  was  engaged  in  attempting  to  write  a  whole  system  of  medicine 
from  the  fcetal  standpoint.  When  th-;etzer  wrote  his  work.  Die 
Krankhciten  des  Fotus,  he  was  able  to  put  most  of  what  was  known 
of  ftttal  pathology  into  273  pages;  but  that  was  in  1837,  and  the 
additions  that  have  been  made  to  our  knowledge  of  the  subject  in 
more  than  sixty  years  have  been  enormous.  One  had  to  comiuence 
to  attempt  to  wiite  a  book  to  realise  how  enormous  the  additions 
had  been.  In  a  broad  sense  the  pathology  of  the  fa?tus  is  co- 
extensive with  that  of  the  adult.  The  foetus  enjoys  a  partial 
immunity  from  the  attacks  of  certain  parasites  which  produce  skin 
diseases  in  post-natal  life,  and  it  is  to  some  extent  protected  from 
external  violence  by  its  environment ;  with  these  exceptions  it  has 
the  same  wide  pathological  possiliilities  as  has  the  child  or  adult. 
Further,  it  is  apt  to  be  affected  with  certain  maladies  in  a  peculiarly 
aggravated  form.  Foetal  diseases,  then,  are,  with  few  exceptions, 
the  diseases  of  postnatal  life  modified  in  certain  ways. 

Limited  Knowledge  of  FcEtal  Pathology. 

While,  liowever,  the  scope  of  fcetal  pathology  is  wide,  the 
opportunities  of  studying  it  are  few  and  our  knowledge  of  it  is 
luuited.  It  has  been  urged  that  if  it  be  true  that  the  foetus  is  liable 
to  all  the  maladies  of  postnatal  life,  it  is  surprising  that  they  are 
not  better  known  and  more  often  met  with  ;  and  it  has  been  added 
that  some  diseases  (their  number  is  Ijeing  rapidly  reduced)  have  not 
been  seen  even  once  in  the  foetus.  These  objections  can  be  very 
easily  remo\'ed.  The  sick  foetus,  unlike  the  sick  child  or  adult,  is 
not  available  for  inspection  save  when  he  is  expelled  from  the 
uterus,  an  occurrence  which  may  take  place  at  any  stage  in  his 
malady — may  not,  indeed,  take  place  at  all  till  after  the  incidence  of 
intrauterine  death  or  the  supervention  of  intrauterine  recovery. 
If  a  physician's  sole  knowledge  of  his  patient  were  limited  to  a 
single  peep  at  him  once  in  a  period  of  seven  months,  it  is  not  to 
lie  ex^jected  that  his  aec_[uaiutauce  with  his  maladies  would  be  either 
extensive  or  accurate.  Further,  if  he  were  unable,  should  his  patient 
chance  to  die,  to  make  an  examination  of  his  corpse  till  some  days 
or  weeks  had  elapsed,  and  lirought  with  them  structural  changes, 
it  is  not  likely  that  the  conditions  then  found  would  throw  much 
hght  upon  the  original  malady.  There  are  other  reasons  why  the 
pathology  of  the  fo'tus  is  comparatively  little  known,  such  as  the  low 
estimate  of  the  value  of  fcetal  life  and  the  invasion  of  the  subject 


174  ANIKNATAL    l>ATH()LO(iV    AND    HVdlKNK 

by  such  uuxciL'iititic  imaginings  as  those  associated  with  maternal 
impressions.  I  have  already  referred  to  the  lack  of  knowledge  of 
the  details  of  foetal  physiology — a  lamental)le  defect,  when  it  is 
remembered  tliat  iiliysiology  is  the  key  to  ])athology — and  there  is 
the  innate  ditticulty  of  the  subject.  These  reasons  are  suHicient  to 
explain  the  paucity  of  published  observations  of  some  of  the  diseases 
of  antenatal  life.  It  may  be  added,  however,  that  the  peculiar 
environmental  conditions  of  the  ftctus,  and  the  prqjecti(ju  of  the 
embryonic  element  into  its  life,  in  a  large  degree  tend  to  mask  the 
resemblance  between  its  diseases  and  those  of  the  cliild  or  adult, 
and  even  to  make  them  appear  essentially  different. 

Classification  of  FcEtal  Morbid  States. 

Many  systems  of  classiticatidii  have  l.icen  used  by  writers  on  fcotal 
pathology  :  some  are  catalogues  and  not  really  classifications  at  all ; 
others  are  etiological,  pathological,  regional,  or  prognostic ;  and  yet 
others  combine  all.  "  A  true  classification,"  it  has  been  .said,  "  is  a 
compendious  expression  of  perfect  knowledge " :  it  need  scarcely  be 
stated  that  such  a  classification  of  fcetal  morbid  conditions  is  not  at 
present  possible.  It  is  also  clear  that  '"  some  provisional  classification 
is  a  necessary  condition  of  increase  of  knowledge,"  and  such  a  pro- 
visional classification  can  be  got  for  fcetal  pathology. 

The  plan  which  I  adopted  in  my  work  on  the  Diseases  of  the  Fiettis, 
and  further  elaborated  in  the  index  of  Teratoloijia  (16),  may  be 
regarded  as  a  combination  of  the  regional  and  the  etiological.  It  is 
manifestly  far  from  perfect ;  it  is  purely  provisional,  and  is  intended 
only  as  a  convenient  and  suggestive  method  of  grouping  togetlier  many 
morbid  states.  It  consists  of  seven  primary  divisions — (1)  transmitted 
diseases,  (2)  transmitted  toxicological  conditions,  (3)  idiopathic  diseases, 
(4)  neoplasms,  (5)  traumatic  morbid  states,  (G)  diseases  of  the  foetal 
annexa,  and  (7)  the  pathology  of  foital  death.  The  last-named 
division  is  entirely  for  convenience,  and  will  be  dispensed  with  when 
the  pathologist  is  al)le  clearly  to  difterentiate  between  the  changes  due 
to  disease  and  those  that  are  post-mortem.  The  dimensions  of  the 
third  group  (idiopathic  diseases)  must  not  be  regarded  as  in  any  degree 
fixed,  for  future  investigations  can  hardly  fail  to  enlarge  the  first 
group  (transmitted  diseases)  at  its  expense.  One  disease,  namely- 
congenital  elephantiasis,  may  be  said  to  be  at  present  on  its  way  from 
the  one  group  to  the  other ;  at  any  rate  the  record  sent  to  me  by 
Dr.  MoncorV'O  of  Ilio  de  Janeiro  {Trans.  Edinh.  Ohst.  Soc,  xxi.,  2'),  189()) 
seems  to  suggest  tiiis  conclusion,  for  in  it  a  woman  who  sutlercd 
from  lymphangitis  in  her  pregnancy  gave  birth  to  an  infant  with 
congenital  elei)hantiasis,  in  whose  Idood  was  the  streptococcus  of 
Fehleisen,  and  the  deduction  was  that  the  new  formation  was  due  tn 
lymphangitis,  set  up  by  the  streptococci  coming  from  the  maternal 
circulation.  With  regard  to  the  neoplasms,  tiiere  can  be  no  doubt 
that  their  origin  in  the  fo'tal  period  is  more  tlian  questionable:  the 
dermoids,  the  teratoids,  the  teratomata,  and  the  included  fu'tu.ses  arc 
certainly  embryonic  nr  germinal  ratlicr  than  fcrtal ;  but,  as  has  lieen 


CLASSIFICATION  175 

already  insisted  upon,  the  classification  is  intended  for  convenience 
rather  than  for  strict  accuracy,  and  in  the  meantime  the  tumours  may 
be  allowed  to  remain  in  it.  An  outUne  of  the  sclieme  of  classification 
is  given  below : — 

Classification  of  Fcetal  Morbid  States. 
I.  Transmitted  Diseases — 

1.  The  Exanthemata,  Malaria,  etc. 

2.  Tuberculosis,  Sepsis,  Elephantiasis,  etc. 

3.  Syphilis. 

II.  Transmitted  Toxicological  State.s — 

1.  Lead-poisoning,-  etc. 

2.  Poisoning  by  Morphine,  Mercury,  Strychnine,  etc. 

3.  Alcoliolism. 

III.  Idiopathic  Diseases — 

1.  Subcutaneous    Tissue    and     Skin,    e.fj.    General     Dropsy, 

Iclithyosis,  etc. 

2.  Osseous  System,  e  cj.  Foetal  Rickets,  Achondroplasia,  etc. 

3.  Alimentary  System,  e.g.  Foetal  Ascites,  Peritonitis,  etc. 

4.  Respiratory  System,  e.g.  Pneumonia,  Hydrothorax,  etc. 

.5.  Circulatory   System,  e.g.    Endocarditis,    Hydropericardium, 
etc. 

6.  Heemopoietic  System,  e.g.  Thyroiditis,  Thymitis,  Hepatitis, 

etc. 

7.  Genito-Urinary  System,  e.g.  Nephritis,  Distended  Bladder, 

etc. 

8.  Nervous  System,  e.g.  Paralyses,  Contractures,  etc. 

IV.  Xeoplasms — 

1.  Of    the    Head   and   Face,    e.g.    Pre-auricular   Appendages, 

Cysts,  etc. 

2.  Of  the  Neck,  e.g.  Cervical  Cysts,  Chondromata,  etc. 

3.  Of  the  Trunk,  e.g.  Sacral  and  Coccygeal  Cysts,  Fibromata,  etc. 

4.  (.)f  the  Extremities,  e.g.  Exostoses,  Lymphangiomata,  etc. 

.5.  Of  the  Internal  Organs,  e.g.  Sarcomata,  Rhabdomyomata,  etc. 

V.  Traumatic  Morbid  States — 

1.  Fractures. 

2.  Dislocation. 

3.  Wounds. 

4.  Congenital  "Amputations." 

YI.  Diseases  and  Morbid  Conditions  of  the  Fcetal  Annexa — 

1.  Placenta,  e.g.  Tubercle,  Qidema,  etc. 

2.  Umbilical  Cord,  e.g.  Knots,  Rupture,  etc. 

3.  Chorion,  e.g.  Abnormal  Vascularity,  etc. 

4.  Amnion  and  Liquor  Amnii,  e.g.  Adhesions,  Hydramnios,  etc. 

5.  Decidual  Membranes,  e.g.  Intiammation,  etc. 


176  ANTENATAL    I>ATIK)I,()(iY    AND    IlVCilKNK 


VII.  Patuology  of  Fcetal  Death — 

1.  Maceration,  ^Mummification,  etc. 

2.  Rigor  Mortis. 

3.  Putrefaction. 

It  will  be  seen  from  a  consideration  of  the  scheme  of  classification, 
that  tlie  niimljer  of  ftetal  morbid  states  is  large.  Even  if  tlie  neoplasms 
be  excluded,  there  still  remain  many  interesting  and  important 
maladies  for  investigation.  It  may  yet  Ije  possible  to  .se])arate  the 
morbid  states  characteristic  of  foetal  life  from  those  cliaractcristic 
of  the  neotVetal  epoch,  just  as  there  is  reason  to  regard  munnnitication 
as  the  special  post-mortem  change  of  the  neoftetus  and  maceration 
as  the  special  alteration  of  the  fcrtus ;  but  in  the  meantime  our 
knowledge  is  insufficient  to  permit  generalisations  of  this  kind. 

Peculiarities  of  Foetal  Morbid  States. 

A  limited  acquaintance  with  fa?tal  diseases  is  sufficient  to  make  it 
plain  tliat  the  maladies  of  the  infant  still  in  utero  differ  from  those  of 
tlie  child  after  birth  in  many  ways  ;  but  the  causes  of  tliese  differences 
are  not  so  plain.  There  must,  however,  be  causes  for  the  peculiarities 
of  foetal  disease,  and  it  has  seemed  to  me  that  there  ai-e  at  least  three 
factors  which  must  be  taken  into  account ;  these  factors  may  lie  named 
the  environmental,  the  placental,  and  tlie  emliryonic.  They  may  be 
best  studied  in  that  order. 

Modifying  Effect  upon  Foetal   Morbid  States  of  the 
Intrauterine  Environment. 

Many  of  the  peculiarities  of  f(etal  morbid  states  find  an  explanation 
in  the  altogether  special  conditions  which  characterise  intrauterine 
existence.  This  influence  is  evident,  or  is  to  be  discovered  if  intelli- 
gently looked  for,  in  most  fa;tal  maladies ;  but  it  is  unnecessary  here 
to  do  more  than  draw  attention  to  its  presence  in  connection  with  the 
exanthemata,  with  icthyosis,  with  fractures  and  wounds,  and  with 
the  phenomena  of  fietal  death. 

The  modifying  effect  of  environment  is  seen  in  the  ciuuacters  which 
some  of  the  exanthemata  take  on  when  they  occur  in  utero.  i'ffital 
variola  is  a  case  in  point.  The  eru]ition  resembles  that  which  occms 
on  mucous  surfaces  in  later  life,  a  fact  which  is  due  in  all  probability 
to  the  inliuencc  which  the  circumambient  liquor  anniii  exerts  u])on 
the  skin  of  the  foetus.  It  keeps  it  moist ;  and  it  is  uncommon  to  find 
a  noteworthy  formation  of  crusts,  and  the  resulting  cicatrices  are  very 
little  marked.  The  pustules  do  not  appear  to  affect  the  face  to  the 
same  extent  as  they  do  in  the  .smallpox  of  later  life;  this  may  lie 
ascribed  to  the  fact  that  in  utero  the  face  is  not  more  exposed  to  tlie 
light  than  any  other  part  of  the  body.  The  external  manifestations 
of  erysipelas  seem  to  be  rare  in  the  fwtus,  and  here  also  the  licpioi- 
amnii  may  be  influential:  ]irobalily,  however,  their  place  is  taken  by 


ENVIRONMENTAL   FACTOR  177 

internal  morbid  clianges,  such  as  endocarditis,  an  instance  of  which 
lias  been  recorded  by  Bidone  {Teratologia,  i.  182,  1894). 

The  idiopathic  maladies  as  well  as  the  transmitted  show  the  effects 
of  the  antenatal  environment ;  in  foetal  ichthyosis,  for  instance,  the 
absence  of  friction  may  be  regarded  as  one  at  least  of  the  causes  of 
the  enormous  epidermic  thickening  which  is  so  characteristic  of  the 
disease.  What  the  action  of  the  liijuor  amnii  can  be  in  cases  of 
ichthyosis  is  not  clear.  It  is  noteworthy,  however,  that  this  fluid, 
which  is  usually  protective,  may  under  certain  circumstances  become 
pathogenic ;  for  E.  Opitz  {Centrlhl.  f.  Gyncik.,  xxii.  553,  1898)  found 
that  the  liquor  amnii  in  hydramnios,  when  injected  into  animals, 
increased  the  formation  of  lymph  and  greatly  irritated  the  kidneys, 
while  the  normal  liquor  had  no  such  effects. 

Apart  from  the  great  traumatism  of  birth,  the  foetus  is  singularly 
free  from  accidents.  Now  and  again  cases  of  severe  maternal  injuiy, 
in  which  the  foetus  has  participated,  have  been  put  on  record,  e.g.  gun- 
shot wounds  of  the  abdomen  and  the  so-called  cow-horn  Ca^sarean 
sections ;  Init  such  occurrences  are  the  rarities  of  sui'gical  literature, 
a  cu'cumstance  which  must  be  in  great  measure  ascribed  to  the  pro- 
tection afforded  to  the  unborn  infant  by  its  environment.  Even  the 
records  of  foetal  fractures  and  wounds,  regarded  usually  as  due  to 
contre-coiq]  in  falls  or  contusions  of  the  mother,  must  be  received  with 
some  scepticism.  Some  time  ago.  Dr.  W.  Easby  of  Peterborough  com- 
municated to  me  the  details  of  a  case  in  which  the  left  clavicle  at 
bu'th  had  the  appearance  of  a  badly  united  fracture.  The  child  was 
a  healthy,  well-formed  girl,  with  no  other  deformities  and  no  osseous 
fragility  ;  there  was  nothing  in  the  labour  or  the  pregnancy  to  suggest 
an  explanation  of  the  state  of  the  clavicle.  Such  cases  may,  in  the 
absence  of  any  more  feasible  theory,  be  ascribed  to  conire-cov/p,  but 
the  evidence  is  slight.  There  have  been  observations  in  which  a 
cicatrix  was  found  over  the  site  of  the  united  fracture,  and  the  con- 
clusion has  been  drawn  that  this  represented  an  intrauterine  com- 
pound fracture.  Further,  in  the  case  of  the  arm  and  leg  bones,  the 
fracture  has  been  met  with  in  association  with  partial  or  complete 
absence  of  one  of  the  bones  or  other  malformation,  e.g.  partial  defect 
of  the  fibula  in  cases  of  fracture  of  the  tibia.  To  my  mind  these 
observations  rather  support  the  idea  that  intrauterine  fractures  rarely 
arise  through  external  violence ;  it  would  seem  as  if  they  had  their 
origin  in  what  may  be  called  amniotic  traumatism.  It  is  conceivable 
that  through  the  formation  of  an  amniotic  adhesion,  the  trace  of 
which  is  left  in  the  cicatrix,  the  soft  cartilage  of  the  developing  bone 
is  distorted,  perhaps  even  broken,  and  the  appearance  of  a  healed 
fracture  produced.  According  to  this  view,  the  accompanying  anoma- 
lies, defect  of  a  bone  or  of  part  of  one,  would  be  easily  explicable  by 
amniotic  pressure.  The  cases  in  which  numerous  fractures  have  been 
found  at  birth  do  not  come  into  this  category;  probably  they  are 
always  due  to  extraordinary  fragility  of  the  whole  osseous  system,  a 
fragility  so  great  that  slight  traumatic  causes,  such  as  jolts,  would  be 
sufficient  to  produce  them.  The  intrauterine  environment,  therefore, 
may  have  this  double  modifying  effect  upon  foetal  traumatic  states  : 


178  ANTENAl'AL    I'AIHOLOGY   AND    HYGIENE 

il  iiiiiy  make  fiacluies  from  external  vi(jlence  very  rare  except  when 
there  is  aljnormal  brittleness  of  the  bones ;  and  it  may  lead,  through 
the  occasional  occurrence  of  amniotic  bands  and  pressure,  to  the 
formation  of  so-called  "  badly  united  fractures." 

With  regard  also  to  the  cases  of  wounds  on  the  skin  of  the  fcctns 
or  areas  of  al)sence  of  the  skin,  there  can  l>e  no  doulit  that  these  are 
not  commonly  caused  l)y  maternal  traumatism — indeed,  the  history 
of  accidents  is  usually  wanting ;  they  find  an  explanation  in  the 
tearing  through  of  amniotic  bands  during  the  process  of  parturition. 
Similarly,  the  so-called  fa^tal  or  spontaneous  amputations  are  scarcely 
traumatic  in  the  ordinary  sense  of  the  term,  although  they  may  be 
due  sometimes  to  funic  or  amniotic  pressure  acting  in  a  somewhat 
traumatic  manner.  These  morbid  states  lie  on  the  border-line  between 
fcetal  pathology  and  teratology  ;  they  afl'ect  structures  which  retain 
their  embryonic  characters  wlien  the  other  parts  of  the  organism 
have  passed  into  tlie  ftetal  period. 

When  the  foetus  dies  in  the  interior  of  the  uterus,  the  post-mortem 
changes  which  ensue  are  rarely  of  a  jiutrefactive  kind :  and  this 
peculiarity  finds  its  explanation  in  the  fo?tal  envii-onment.  In  its 
intrauterine  position  the  foetus  is  protected  from  putrefactive  organ- 
isms, save  only  in  the  cases  in  which  ruptvu'C  of  the  inendjranes  has 
taken  place  before  the  supervention  of  labour.  Further,  it  is  sur- 
rounded by  the  warm  liquor  amnii,  a  medium  which  specially  favours 
the  occurrence  of  the  macerative  changes  which  are  the  juithological 
expression  of  foetal  death.  Maceration,  then,  is  the  process  which  the 
foetal  body  undergoes  when  death  occurs  in  utcro  and  when  the  mem- 
In'anes  remain  unruptured.  Occasionally,  however,  another  non- 
putrefactive  change  is  met  with,  namely,  mummification,  the  result 
of  which  is  the  production  of  the  fcetus  compressus  or  papyraceus. 
This  occurs  more  especially  when  the  dead  fa'tus  is  not  alone  in  the 
uterus,  but  is  in  the  presence  of  a  living  twhi,  which  in  the  process  of  ( 
growth  pushes  it  to  one  side  and  compresses  it.  ^lummitication  seems 
specially  to  characterise  earh'  foetal  or  neofoetal  death.  In  cases  of 
intrauterine  death,  therefore,  the  peculiarities  of  the  environment  not  i! 
(nily  impress  themselves  upon  the  fcetal  organism,  but  also  have  an 
important  and  beneficial  effect  upon  the  mother,  saving  her  in  many 
instances  from  blood-poisoning. 

There  is  one  point  in  connection  with  foetal  death  to  which  it  is 
necessary  to  allude  because  of  its  im])ortant  medico-legal  bearings — 
namely,  rigor  mortis  in  the  unborn  infant.    There  is  no  evidence  to  show- 
that  the  fcetal  environment  prevents  the  occurrence  of  rigor  mortis, 
yet  it  is  commonly  believed  that  if  the  new-born  infant  shows  post- 
mortem rigidity,  it  must  of  necessity  have  been  alive  at  the  time  of  ■ 
birth.     This  dictum,  which  has  Caspar's  weighty  authority  to  support 
it,  has  not  seldona  had  an  important  liearing  in  cases  of  trial  for  I 
suspected  infanticide.     I  have  elsewiiere  (80)  entered  fully  into  this  ■ 
cpiestion,  and  have  proven,  liotli  from  personal  observations  and  from 
]iublished  arses,  that   the  fcetus  which  dies  in  utero,  even  when  it 
is  also  premature,  shows  unmistakable  rigor  mortis,  and  that  tliis 
muscular  rigidity  may   be   the  cause   of   difficulty   in   labour.     The 


PLACENTAL   FACTOR  179 

iiniuature  coiulition  of  the  muscular  system  and  the  peculiarities 
of  the  environment  may  lead  to  a  shorter  and  less  intense  rigidity ; 
but  that  it  occurs  is  certain. 

The  Placental  Factor  in  FcEtal  Pathology. 

The  modifying  eftect  upon  foetal  morbid  states  of  what  may  be 
called,  for  the  sake  of  brevity,  the  placental  factor,  might  have  been 
considered  under  the  head  of  the  Intrauterine  Environment,  for  the 
placental  influence  is  really  essentially  environmental ;  but  it  is  so 
important  and  so  altogether  special  in  its  action,  tliat  it  has  seemed 
best  to  me  to  discuss  it  separately. 

The  predominant  part  played  by  the  placenta  in  the  physiolog}' 
of  the  foetus  has  been  referred  to ;  its  role  in  ftetal  respiration, 
secretion,  excretion,  and  metabolism  has  been  considered  ;  it  has  l^een 
suggested  that  it  is  much  more  than  a  simple  mechanical  or  biological 
filter,  through  which  materials  pass  by  the  laws  of  osmosis  from  one 
economy  to  another ;  and  it  has  been  hinted  that  it  is  an  important 
gland,  with  a  secretion,  with  powers  of  independent  metabolic  activity, 
and  with  physiological  possibihties  which  are  at  present  much  under- 
estimated. In  the  placenta  the  maternal  and  the  f(etal  blood  come 
into  physiological,  although  not  into  anatomical  contact ;  they  come 
near  enough  to  each  other  to  exchange  some  of  their  constituent 
parts,  but  they  do  not  touch.  It  cannot  be  doubted  that  the  placenta 
has  an  equally  important  effect  upon  the  pathological  developments 
of  fffital  life.  What  this  effect  is  must,  in  the  present  state  of  our 
knowledge  of  fcetal  physiology  and  pathology,  be  left  in  some  degree 
uncertain :  but  there  are  several  standpoints  from  which  it  may  be 
regarded,  and  from  these  points  the  reader  is  invited  to  survey  it. 

In  the  first  place,  the  presence  of  the  placenta  makes  it  possible 
for  the  fcetus  to  be  diseased  in  structure  to  a  very  advanced  degree 
without  the  suspension  of  its  vitality.      An  enormous  amount  of 
morbid  change  may  be  present  without  the  cutting  short  of  intra- 
uterine  life.     So   long,  for   instance,  as  the   foetal  malady  attacks 
organs  whose  functions  are  performed  in  whole,  or  even  in  part,  by 
the  placenta,  the  induced  morbidity  is  only  potential.     The  lungs 
'.  may  be  solid  from  pneumonia,  and  yet  no  inconvenience  be  caused 
I  to   the   foetus  quA  the  state  of  its  lungs  so  long  as  the  placental 
I  economy  is  maintained.     The  kidneys  may  have  their  whole  sub- 
'  stance   converted   into   cysts   without   the   foetus   suffering   to   any 
i  appreciable   extent,   and    the   intestinal    canal    may    be    blocked    in 
I  several   places   without   symptomatological   effects.      The   potential 
!  morbidity   of  intrauterine  life  becomes  real  at  birth ;    for  instance, 
i  an  imperforate  condition  of  the  liile-ducts  which  has  not  interfered 
!  with  foetal  health  begins  to  set  up  marked  sjniiptoms  as  soon  as  there 
i  is  an  organic  severance  from  the  maternal  economy.     The  potential 
I  mortality  of  the  foetus  is  another  eftect  of  the  placental  predominance. 
I  An  amount    of   structiu'al    change   quite   incompatible   with    extra- 
I  uterine  existence  may  be  present  in    utero   without  causing  fcetal 
I  death.     A  foetus   with  general   dropsy  may  come  to  the  full  term 


180  AXTFAATAI.    l'Aril()L()(;V    AND    HYCilKNK 

with  its  periliiueal,  iicriL-anlial,  and  pleural  cavilit's  loailud  with 
Uiiid  and  witli  advanced  changes  in  its  internal  organs ;  it  may  even 
show  signs  (if  life  at  birth ;  yet  it  invarialily  dies  in  a  few  minutes, 
or  at  most  hours,  thereafter.  Tlie  general  dropsy  was  compatible 
with  an  intrauterine,  but  not  with  an  extrauterine  existence.  With 
the  occurrence  of  birth  the  infant  found  itself  in  conditions  in  wiiich 
its  diseased  organs  were  no  longer  alile  to  conserve  life:  the  potential 
mortality  became  real.  I  liave  already  referred  tn  the  enormous 
amount  of  teratological  change  which  nught  be  present  in  the  fa^tus 
without  causing  its  intrauterine  death.  It  is  thus  possible  for  a 
monstrous  embryo  to  be  l)orn  into  its  neofretal  pei'iod  of  existence  and 
to  be  carried  through  the  whole  of  ftetal  life  without  interruption. 
The  monstrosity  is  produced  in  the  embryonic  epoch;  but  the  wrong 
lines  of  development  then  laid  down  continue  to  he  followed  in  the 
ftctal  period,  and  the  ])roccss  is  imly  brought  to  a  conclusion  by 
death,  when  the  organism  is  Y>i'o.jected  into  a  non-jilacental  environ- 
ment. In  this  manner  the  placenta,  by  preventing  intrauterine 
death,  no  doubt  often  saves  the  mother  from  the  risks  of  prema- 
ture confinement ;  liut  for  this  effect  the  prolongation  of  the  life 
of  a  diseased  or  monstrous  fu'tus  would  seem  to  be  an  unmixed 
evil  (44). 

The  placental  factor  in  foetal  pathology  may  lie  looked  at  fmni 
a  second  standpoint:  the  placenta  may  be  regarded  as  a  protection  t" 
the  foetus,  as  a  barrier  preventing  sometimes,  if  not  always,  the 
passage  of  poisons  and  toxines  from  a  diseased  maternal  organism  to 
the  fcetus.  Porak  (Arch,  dc  mM.  expir.  et  d'anat.  path.,  vi.  192, 1894) 
and  others  have  experimentally  demonstrated  some  of  the  ways  in 
which  the  placenta  acts  with  regard  to  poisons  in  the  maternal 
circulation.  It  has  been  shown  that  it  has  a  real  affinity  for  some 
toxic  substances ;  and  in  it  accumulate  copper  aiul  mercury,  Init  not 
lead.  In  addition  to  its  pulmonary,  renal,  and  intestinal  functions, 
the  placenta  fixes  glycogen  and  acts  as  an  acciunulator  of  poisons, 
and  so  resemliles  in  its  action  the  liver  in  the  adult.  This  has  been 
leferred  to  in  the  preceding  chapter.  But  the  storing  up  of  poisons 
in  the  placenta  is  not  so  general  as  the  accumulation  of  them  in  the 
liver  of  the  mother.  While  the  placenta  stcu'es  up  poisons,  it  does 
not  on  that  account  altogether  prevent  their  passage  into  the  fcetal 
tissues ;  it  does  not  act  as  a  complete  liarrier.  It  otters,  however,  a 
varying  degree  of  obstruction  to  their  passage;  it  allows  cojiper  ami 
lead  to  pass  easily,  arsenic  with  greater  difficulty,  and  mercury 
apparently  not  at  all,  for  Porak  always  found  it  in  the  placenta  and 
never  in  the  fcrtal  organs.  These  observations,  it  must  be  remem- 
bered, were  made  on  guinea-pigs,  and  do  not  of  necessity  apply  to  the 
human  subject;  but  in  the  absence  of  other  evidence  they  have 
n  considerable  value. 

Willi  regard  to  the  action  of  the  placenta  as  an  accunnilatni- 
(jf  pathogenic  microbes  and  their  toxines,  and  as  a  barrier  to  their 
passage  to  the  foetus,  a  great  deal  has  been  learned  during  the  last 
fifteen  or  twenty  years ;  but  the  problems  which  yet  remain  for 
solution  are  very  numerous  and  the  difficulties  associateil  with  them 


PLACENTAL   FACTOR  ISl 

are  exti'iuii'diuary.  The  idea  that  the  placenta  acts  alwcu/s  as  a  filter, 
keeping  back  the  bacilli  and  cocci  which  may  be  present  in  the 
maternal  circulation,  and  so  saving  the  fa?tus  from  their  evil  eftects, 
must  be  abandoned.  That  the  placenta  acts  often  as  a  prophylactic 
filter  is  also  open  to  grave  doubt.  Bacteriological  researches  have 
shown  that  through  it  can  pass  the  bacilli  of  anthrax,  of  fowl  cholera, 
and  of  typhoid  fever,  the  pneumococcus,  the  streptococcus,  the  spiril- 
lum Obermeieri,  the  bacillus  of  glanders,  the  pathogenic  organism  of 
hydrophobia,  and  perhaps  the  ha^matozoon  of  malaria.  Fuither,  it  is 
not  necessary  to  atlniit  the  existence  of  a  placental  lesion  to  explain 
the  passage  of  the  micro-organism;  for  in  the  case  of  animals,  at 
any  rate,  the  most  rigorous  examination  of  placentas  through  which 
bacteria  have  been  transmitted  has  sometimes  shown  neither  macro- 
scopic nor  microscopic  changes  in  them.  For  the  infants  of  even 
seriously  tuljercular  women  to  be  found  showing  tuljercular  changes 
at  birth  is  a  rare  occurrence,  and  it  is  only  during  recent  years  that 
congenital  tuberculosis  has  been  definitely  proven  Ijy  the  discovery 
of  the  tubercle  bacillus  in  the  foetal  tissues  and  in  the  placenta.  In 
this  disease,  therefore,  if  in  any,  it  might  be  expected  that  the  bene- 
ficent role  of  the  placenta  would  be  demonstrable.  Georges  Kiiss 
(X*e  I'herediU  2^(i'rasitairc  de  la  tiibcrculosc  humainc,  Paris,  1898),  who 
has  investigated  the  whole  question  of  tubercular  heredity  in  a  very 
complete  fashion,  is  of  opinion  that  even  when  the  tubercle  bacilli 
make  their  way  into  the  placenta,  that  structure  has  still  the  power 
of  protecting  the  fcetus  from  the  microbic  invasion.  He  adduces  in 
support  of  his  statement  the  two  cases  of  Lehmann,  in  which  the 
infants  were  free  although  the  placentas  were  tuliercular,  and  those 
of  Schmorl  and  Kockel,  in  which,  although  there  was  placental  tuber- 
culosis and  some  bacilli  were  found  in  the  vessels  of  the  chorion,  yet 
neither  the  microscope  nor  experimental  inoculations  revealed  the 
presence  of  fcetal  bacillosis.  Kiiss  also  noted  that  the  fa?tuses  that 
showed  infection  always  had  a  much  less  marked  bacillosis  than 
might  have  been  expected  from  the  intensity  of  the  maternal  blood- 
infection  and  from  the  advanced  state  of  the  placental  lesions.  It 
seems,  therefore,  fair  to  conclude  that  in  tuberculosis,  at  any  rate,  the 
number  of  germs  that  pass  through  the  placenta  is  very  small.  It 
must  also  be  borne  in  mind,  however,  that  even  where  the  organs  of 
the  fcetus  of  a  tubercular  mother  appear  healthy,  inoculation  of 
animals  with  pieces  of  them  sets  up  in  some  instances  undoubtedly 
tuberciUar  processes.  Possibly  infective  toxines  may  pass  even  when 
the  bacilli  do  not.  The  placenta  cannot,  therefore,  be  regarded  as 
a  complete  or  certain  barrier  to  microbic  invasions  even  in  the  best 
circumstances. 

Third,  it  is  now  necessary  to  look  at  the  placental  factor  from 
quite  the  opposite  standpoint,  viz.,  as  the  chief,  if  not  the  only  avenue 
of  access  for  germs  to  the  foetus.  Practically  the  only  other  way 
possible  from  the  mother  to  the  fa?tus  is  by  the  liquor  amnii.  Cer- 
tainly the  researches  of  P.  L.  Ferrari  {Lo  Spcrimcntak,  Ann.  xlix.,  sez. 
biologica,  fasc.  L,  p.  62,  1895)  on  the  structure  of  the  amniotic  mem- 
brane seem   to  show   that   through  its  stomata  materials  may  pass 


lS-2  ANTKNATAI.    I'AIHOI.OdV    AND    HYCIKNF, 

fi(jiii  the  lymphatic  system  of  the  mother  into  tiie  liquor  amnii  and 
then  to  the  fcctus  by  the  mouth  and  intestinal  tract  (rule  Chapter 
X.)  While,  however,  it  is  right  to  regard  this  as  a  possible  mode  of 
entrance,  it  cannot  be  looked  upon  as  a  common  one.  I'robably 
"  water-liorne  infection"  is  very  rare  in  the  foetus.  It  follows,  there-  . 
fore,  that  the  placental  route  is  practically  the  only  one  from  mother  ■ 
to  fietus ;  and  it  is  a  matter  of  some  importance  to  determine  the 
circumstances  that  increase  or  diminish  placental  permeability  to 
I)oisous  and  germs.  Our  knowledge  of  these  circumstances  i.s  im- 
perfect, but  the  following  conclusions  seem  warranted.  It  is,  for 
instance,  apparent  from  the  study  of  the  comparative  anatomy  of  the 
placenta,  that  its  permeability  must  vary  in  different  species,  according 
to  the  thickness  of  tissue  intervening  between  tlie  maternal  and  fo'tal 
circulations.  It  would  appear  from  the  extensive  researches  of  Duval, 
that  in  this  respect  the  himian  placenta  occupies  an  intermediaie 
position  between  that  of  the  rodents  and  that  of  the  ruminants.  In 
the  rodent  the  barrier  is  very  slight ;  in  the  ruminant  there  is  a  ' 
fourfold  barrier,  two  capillary  walls  and  two  epithelial  layers,  between 
the  maternal  and  the  ffctal  Ijlood.  There  would  seem  to  be  no  need 
for  a  lesion  in  the  former  case,  while  in  the  latter  some  morbid  change 
would  almost  appear  to  be  neces.sary,  before  germs  or  their  toxinesi 
could  pass  from  mother  to  foetus.  Again,  there  is  reason  to  believe 
that  placental  permeability  varies  at  the  different  epochs  of  preg-' 
nancy;  this  conclusion  seems,  at  any  rate,  to  be  warranted  in  the 
case  of  the  rodents.  The  experiments  of  Charrin  and  Duclert  {Ctrmpt. 
rend.  Soc.  de  hiol.,  p.  5G3,  July  13,  1894)  are,  however,  full  of  interest 
in  relation  to  the  question  of  placental  transmission,  and  deserve 
notice.  These  observers  found  that  certain  conditions  of  the  maternal, 
blood  favoured  the  passage  of  germs  through  the  placenta ;  ths' 
presence  in  the  blood  of  microl)ic  toxines,  c.ff.  tuberculin,  as  well  asi 
of  acetate  of  lead,  alcohol,  or  lactic  acid,  seemed  to  increase  in' 
a  marked  manner  the  permeability  of  the  placenta.  Previous' 
inoculation  with  corrosive  sublimate,  on  the  other  hand,  seemed 
to  make  it  more  difficult  for  microbes  to  pass.  It  would  almost 
appear  as  if  the  prolonged  presence  of  the  microbes  in  the  neigh- 
bourhood of  the  barrier  led  to  the  breaking  down  of  it  l)y  the 
action  of  the  toxinic  products  of  microbic  vitality.  The  experiments 
it  must  be  borne  in  mind,  were  performed  on  guinea-pigs ;  never- 
theless they  have  at  least  a  suggestive  value  as  regards  the  human 
subject. 

There  can  be  no  doulit,  therefore,  that  although  its  ]iermealiilit} 
varies,  the  placenta  is  the  avenue  by  which  germs  and  ])oisons  read 
the  fictus.  This  circumstance  has  a  very  considerable  bearing  upoi' 
the  i)ositiou  of  primary  lesi(ms  in  the  foetus.  The  infection  reaches 
tiie  body  of  the  unborn  through  the  blood,  and  traverses  first  th( 
placenta  and  the  umliilical  cord,  then  the  umbilical  vein,  then  eithe 
the  liver  or  the  ductus  venosus,  then  the  heart,  and  so  is  distributee 
to  the  whole  organism.  It  is  no  matter  for  wonder,  therefore,  tha 
the  primary  jiathological  changes  are  commonly  found  in  the  placenta 
liver,  or  heart.     In  this  way  it  is  quite  easy  to  understand  how,  ii 


PLACENTAI>   FACTOR  183 

such  a  case  as  that  reported  liy  Bidoiie  (loc.  cit.),  erysipelas  in  the 
mother  does  not  produce  skin  lesions  in  the  foetus,  but  streptococcic 
endocarditis.  The  locality  of  the  lesions  is  determined  by  the  route 
of  invasion.  Similarly,  in  congenital  tuberculosis  it  is  rare  to  find  the 
morbid  process  in  the  lungs,  and  in  half  the  certain  reported  cases  the 
pulmonary  tissue  was  devoid  of  lesions.  It  is  true  that  the  liver  was 
not  invariably  tubercular,  but  it  is  possible  that  in  such  cases  the 
infection  passed  outside  the  liver  straight  through  the  ductus  venosus 
to  the  heart  and  general  circulation.  If  i^rimary  lesions  exist  at  all 
in  fffital  syphilis,  they  are  to  be  sought  for  not  on  the  skin  or  the 
mucous  surfaces,  but  in  the  placenta  or  liver  or  heart.  What  has  been 
said  of  the  distribution  of  diseases  applies  also  to  the  invasion  of  the 
foetal  body  by  mineral  or  vegetaljle  poisons,  and  Porak  {loc.  cit.) 
has  called  special  attention  to  this  in  his  experimental  work. 
Thus  a  great  many  of  the  peculiarities  of  foetal  diseases  are  to  be 
accounted  for,  and  it  becomes  more  and  more  apparent  that  the 
pathology  of  the  foetus  is  simply  postnatal  pathology  modified  by 
the  special  phvsiological  conditions  which  exist  during  this  period 
of  life. 

There  is  a  fourth  aspect  in  which  the  placental  factor  in  foetal 
pathology  has  to  be  considered,  viz.  the  lethal  effect  iipon  the  foetus  of 
lesions  of  the  placental  substance.  It  has  been  pointed  out  that  the 
presence  of  the  intact  placenta  preserves  the  life  of  the  fcetus  even  when 
its  organs  are  most  extensively  diseased.  The  placenta  is  in  this  sense 
the  most  vital  organ  that  the  foetus  possesses ;  but  it  is  also  the  most 
vulnerable.  When  it  is  itself  the  seat  of  lesions,  the  life  of  the  unborn 
infant  is  immediately  in  grave  danger.  All  placental  lesions  are  not, 
of  course,  equally  lethal  to  the  fcetus,  and  I  have  noted  cases  of  cysts 
on  the  foetal  aspect  and  of  calcareous  deposits  on  the  uterine  along 
with  perfectly  healthy  infants ;  but,  as  a  general  r\de,  disease  of  the 
placenta  means  death  of  the  fretus,  or,  what  comes  to  the  same  thing, 
premature  expulsion  of  it  from  the  uterus.  It  is  of  great  importance, 
in  studying  the  causes  of  abortion  and  premature  labour,  to  remember 
that  the  placenta  is  an  organ  of  the  foetus.  During  the  last  few  years 
I  have  been  frecjuently  asked  to  state  the  cause  of  foetal  death  and  of 
premature  delivery  from  the  examination  of  the  foetus  alone.  It  is 
scarcely  ever  possible  to  do  so,  for  tlie  cause  of  the  fatal  result  is  most 
often  in  the  very  structure  that  is  not  available  for  examination  I 
cannot  too  strongly  insist  upon  the  fact  that  a  foetus  without  the 
placenta  and  membranes  is  an  incomplete  specimen.  To  attempt  to 
give  an  opinion  from  it  alone  resembles  trying  to  find  out  the  cause 
of  death  in  a  case  of  head  injury  from  the  dissection  of  the  thorax 
and  abdomen.  A  conclusion  of  some  kind  may  be  reached  by  a 
process  of  exclusion,  but  its  value  cannot  be  very  great.  The 
placental  filter,  then,  may  save  the  fcetus  sometimes  from  disease, 
but  it  may  do  so  at  the  cost  of  foetal  life.  It  may  prove  a  barrier  to 
the  disease  germs,  but,  inasmuch  as  the  barrier  is  the  most  essential 
organ  that  the  foetus  possesses,  this  protective  influence  may  be  very 
dearly  bought.  The  placenta,  in  saving  the  fa>tus  from  disease, 
becomes  pathological  itself,  and  so  condemns  it  more  certainly  to 


184  ANTKAATAL   I'A'I'HOLOCY   AND   HYfHFA'E 

death.  Tliere  may  exist  some  doulit  as  to  tlie  exact  nature  of  the 
morbid  cliauges  in  the  foetus  which  alcoholism  in  the  nu)ther  tends  to 
produce  (J.  Matthews  Duncan,  Trans.  Edinh.  Ohatd.  Soc,  xiii.  105, 
1888);  but  there  can  be  no  doubt  at  all  about  the  frequency  with 
which  abortion  and  premature  labour  from  placental  lesions  occur 
under  these  circumstances.  When  it  is  borne  in  mind  that  the 
placenta  is  lungs,  stomach,  and  kidneys  to  the  foetus,  it  is  easy  to 
understand  how  pathological  changes  in  it  soon  lead  to  fatal  results 
in  the  latter. 

From  yet  a  fifth  standpoint  the  placenta  may  be  regarded  in 
connection  with  its  effect  upon  foetal  morbid  processes.  By  reason 
of  its  highly  differentiated  tissue  and  its  active  metabolism,  it  may 
act  upon  pathogenic  substances  in  other  and  more  subtle  ways  than 
by  simply  opposing  a  barrier  to  their  passage  from  mother  to  fui'tus. 
It  is  possible  that  it  may  secrete  products  which  may  act  as  anti- 
toxiues  ;  it  is  also  possible  that  under  certain  circumstances  it  may 
liy  a  disordered  metabolism  produce  materials  which  increase  the 
virulence  of  attacking  germs  or  weaken  the  natural  defences  of  the 
placental  tissues.  Again,  it  is  possible  that  too  much  speculation 
may  retard  rather  than  advance  our  knowledge  of  this  whole  subject 
of  the  influence  of  the  placenta  in  fo-tal  pathology. 

There  is,  however,  one  other  point  to  which  some  reference  must 
here  be  made,  although  it  must  be  conceded  that  it  also  is  largely 
speculative.  Thus  far  I  have  dealt  only  with  the  transmission  of 
disease  from  mother  to  fcetus ;  but  it  may  be  asked  whether  the 
current  is  not  sometimes  reversed  or  capable  of  being  reversed,  and 
morbid  influences  pass  from  foetus  to  mother  ?  From  what  has  been 
stated  in  the  preceding  chapter  regarding  the  excretory  functions  of 
the  placenta  and  the  experimental  evidence  associated  with  them, 
there  is  a  presumption  at  any  rate  in  favour  of  the  reverse  current 
as  regards  disease.  I  have  referred  also  to  the  fact  that  Charrin 
(Compt.  rend.  held,  dc  I'Acad.  des  Sc,  Paris,  cxxvii.  332,  1898)  has,  in 
the  case  of  animals,  succeeded  in  killing  the  mother  by  injecting  the 
toxine  of  Ltiffler's  bacillus  into  the  foetuses  in  utero ;  it  may  be  found 
to  be  possible  by  making  progressive  injections,  thus  to  render  the 
mother  immune  against  the  poison  of  diphtheria.  We  are  tempted 
to  ask  ourselves  whether  the  fact  that  the  ]>acillus,  toxine,  or  poison 
reaches  the  mother  by  the  placental  route  will  in  any  way  modify 
the  results  produced  thereliy  in  the  maternal  organism  ?  Again,  will 
the  physiological  condition  of  the  woman  in  pregnancy  (anjemia, 
hyposiderosis)  increase  or  diminish  her  susceptibility  to  the  morlml 
intiuences  coming  to  her  from  the  fo'tus  ?  Does  the  i)lacenta  liy  its 
metabolic  activities  or  its  internal  secretion  (not  j'et  demonstrated) 
intensify  or  reduce  the  virulence  of  the  germs  or  toxines  ?  The 
whole  question  of  the  effect  of  foetal  morbid  processes  upon  maternal 
predisposition  and  immunity  can  hardly  Ije  regarded  as  more  than 
toucheil  at  present,  and  much  remains  to  be  done  before  any  con- 
clusions can  ))e  drawn  with  security.  Certainly  the  problem  of  a 
mother  with  an  acquired  immunity  against  smallpox,  scarlet  fever, 
measles,  etc.,  carrying  in  her  womb  a  fietus  with  an  almost  certain 


EMBRYONIC   FACTOR  185 

predisposition  to  take  any  or  all  of  these  very  diseases,  is  most 
interesting  and  complicated.  As  complicated  and  as  interesting  is 
the  state  of  a  mother  who  has  not  got  syphilis  and  who  is  yet  in 
physiological  contact  throngh  the  placenta  with  a  foetus  who  is 
syphilitic  because  of  the  syphilis  of  the  father.  It  seems  necessary 
to  grant  the  existence  of  this  reverse  current  of  pathological  influence 
proceeding  from  foetus  to  mother,  if  we  are  to  offer  any  explanation 
of  the  occurrence  of  telegouy,  the  wii-eless  telegraphy  of  antenatal 
pathology  ;  without  such  a  mechanism  it  is  impossible  to  understand 
how  characters  of  a  previous  sire  can  be  transmitted  to  the  progeny 
of  a  later  one  by  the  mother ;  of  course,  in  cases  of  telegony  it  would 
also  be  necessary  to  predicate  the  possibility  of  the  ova  in  the  ovaries 
becoming  imbued  with  paternal  characteristics  apart  from  actual 
impregnation.  Many  and  difficult  are  the  problems  which  present 
themselves  to  those  who  are  courageous  enough  to  attempt  to  study 
the  laws  of  the  phenomena  of  generation. 

The  Embryonic  Factor  in  Fcetal  Pathology. 

While  the  placenta  and  the  intrauterine  environment  serve  to 
account  for  some  of  the  peculiarities  of  fcetal  maladies,  they  leave 
unexplained  not  a  few.  The  occurrence  which  complicates  fcetal 
pathology  so  greatly  is  the  projection  into  it  of  the  results  of 
embryonic  pathology.  It  is  an  error  to  suppose  that  every  morbid 
condition  found  in  the  infant  at  the  moment  of  bu'th  must  have 
arisen  during  parturition  or  in  the  foetal  period.  It  is  common  to 
speak  of  "  foetal "  monstrosities,  but  if  by  this  it  is  meant  that  the 
monstrosities  in  question  are  the  result  of  foetal  pathological  processes 
the  notion  is  probably  erroneous.  There  is  good  reason  for  believing 
that  malformations  and  monstrosities  are  the  product  of  morbid 
agents  acting  during  the  embryonic  period.  The  foetus  is  born,  as  it 
were,  into  fcetal  life  with  all  the  results  of  embryonic  pathology  in  it ; 
so  long  as  these  are  not  incompatible  with  the  continuance  of  fcetal 
life,  it  goes  on  growing,  and  may  reach  the  full  term  and  be  transferred 
into  extrauterine  life,  still  bearing  the  evident  traces  of  its  embryonic 
troubles.  It  is  probable  that  the  original  malformations  do  not 
during  the  fa3tal  period  greatly  alter  in  their  appearances ;  they  grow 
witli  the  general  growth  of  the  body,  and  may,  according  to  cir- 
cumstances, become  more  or  less  marked,  but  they  retain  their 
essential  characters.  They  may,  however,  have  a  very  important 
bearing  upon  the  development  of  fcetal  diseases,  and  their  coexist- 
ence with  them  certainly  makes  their  pathology  very  difficult  to 
understand.  The  difficulty  is  still  further  increased  by  the  fact 
to  which  allusion  has  already  been  made,  that  the  whole  organism 
does  not  at  once  pass  out  of  the  embryonic  into  the  fcietal  period. 
It  comes  about,  therefore,  that  the  foetal  bone  diseases  are  specially 
difficult  to  understand,  for  they  are  really  deformities  originating 
during  the  period  which  as  a  whole  is  characterised  by  the  pro- 
duction of  diseases. 

Some  years  ago  it  was  a  very  commonly  accepted  theory  that 


186  ANTKNATAI.    I'ATHOLOdY    AND    HVCUENE 

monstrosities  wcw.  cmusimI  hy  ilie  occurrt'iico  of  diseases  in  the  foetus, 
and  Sir  .lames  Simjison  (iimonj^  others)  gave  the  weight  of  liis  avitlior- 
ity  to  the  view.  Modern  research  has  not  supported  this  theory. 
Duval  ("Pathogenic  generale  de  Tenibryon,"  in  Bouchard's  TraiU  de 
patholor/ie  gi'm'rale,  i.  159,  1895),  especially,  decides  against  it,  and 
distinctly  states  that  it  is  not  to  be  thought  that  a  malformation  of  • 
any  part  i.s  the  result  of  a  disease  from  which  the  malformed  part  has 
suffered.  With  this  I  in  part  concur;  but  I  tliink  that  just  as  a  pre- 
existing malformation  may  influence  the  progress  of  a  fcetal  disease, 
so  a  fo-'tal  disease  supervening  upon  a  malformation  may,  during  the 
seven  months  of  foetal  life,  very  considerably  alter  its  manifestations 
as  seen  at  birth.  Further,  the  cause  of  the  malformation  may  not 
cease  to  act  with  the  close  of  the  embryonic  period ;  it  may  continue 
to  act  in  the  fcetal ;  in  this  waj'  it  may  be  the  cause  of  both  the 
deformity  and  the  disease.  For  instance,  a  malformation  of  the 
intestine  and  ftetal  peritonitis  often  coexist ;  both  may  be  the  result 
of  one  and  the  same  cause ;  but  it  may  also  quite  well  be  that  the 
existence  of  the  disease  has  influenced  the  nature  of  the  malformation, 
and  that  the  malformation  has  made  the  disease  more  or  less  active. 
Exomphalos  is  a  manifestly  teratological  condition,  and  there  often 
exists  along  with  it  a  great  amount  of  peritonitic  fixation  of  the 
abdominal  viscera,  a  fact  upon  which  stress  has  been  laid  Ijy 
A.  Eischpler  (Archiv  f.  Entwickdurujs-mechnnik  dcr  Organismcn,  vi. 
556,  1898),  but  it  seems  to  me  that  all  this  association  shows 
is  that  some  common  cause  acting  specially  on  the  abdominal 
region  has  Ijeen  at  work  during  the  embryonic  and  the  fcetal  period. 
Peritonitis  coming  on  during  the  foetal  epoch  may  exaggerate  or 
alter  the  appearance  of  the  exomphalic  condition,  but  it  is  doubtful 
whether  it  is  in  any  sense  either  the  cause  or  the  result  of  tlie 
exomphalos.  The  consideration  of  the  embryonic  factor  takes  into 
account,  therefore,  («)  the  modification  of  fcetal  diseases  liy  pre- 
existing malformations,  and  (6)  the  modification  of  malformations  liy 
coexisting  diseases. 

In  the  preceding  pages  I  have  attempted  to  describe  three  possible 
factors  which  play  a  part  in  modifying  the  diseases  which  att'ect  the 
fcEtus  and  give  to  them  their  peculiar  characters.  Doubtless  there 
are  other  factors,  but  the  existence  of  these  three — environment,  the 
placental  influence,  and  the  embrj'onic  complication — must  be  recog- 
nised. In  order  to  make  the  matter  somewhat  simpler,  I  may  compare 
the  fu?tus  to  a  tra\el]er  coming  from  a  tro])ical  climate  to  our  country. 
He  finds  himself  in  a  new  environment  wliich  in  many  details  difl'ers 
much  from  that  which  he  has  left,  and  wliich  gives  new  chai'acters  to 
the  diseases  which  he  now  develops.  Further,  through  his  dress  and 
modes  of  life,  he  lays  liimself  open  to  taking  certain  maladies  more 
often  and  in  more  serious  forms  than  ])reviously,  while  from  others  he 
may  perhaps  be  protected.  In  the  third  jJace,  lie  comes  to  our  country 
with  the  results  of  the  diseases  from  wliich  he  has  already  sufl'ered  in 
his  own  land  in  him  and  part  of  him;  and  these  earlier  pathological 
experiences  also  influence  the  course  of  the  morbid  states  which  he 
ac(juires  later. 


PROBLEMS   IN   FCETAl,   PATHOL()(;Y  187 

Fcetal  pathology, then, presents  many  difficult  problems  for  solution. 
It  asks  how  pathological  processes  are  altered  by  the  presence  of  the 
li(luor  amnii  and  by  the  absence  of  atmospheric  air  and  light;  it  calls 
for  a  definition  of  the  action  of  the  placenta  in  the  preservation  of 
health  or  the  production  of  disease  in  the  foetus ;  and  it  places  promi- 
nently before  us  the  extraordinarily  complicated  question  of  the 
inter-action  and  inter-relation  of  emln-yonic  malformations  and  foetal 
diseases  in  the  foetal  period  of  the  existence  of  the  organism.  Path- 
ologists of  the  future  have  no  light  task  before  them  in  the  solving  of 
these  problems. 


CHAPTER    XII 

Types  of  Traiisniilted  Fcrtal  Diseiises.  Fcftal  Variola:  Patliofjenelic  Possi- 
bilities ;  Clinical  Peculiarities ;  Diagnosis,  Prognosis,  and  Treatment. 
Fietal  Vaccinia ;  Antenatal  Inununity.  FcBtal  Measles,  Scarlet  Fever, 
Erysipelas,  Parotitis,  Influenza,  Pertussis,  Relapsing  Fever,  Yellow  Fever, 
and  Cholera.  Fcetal  Typhoid;  Pathogenetic  Possibilities;  Widal  Test  in  the 
FcEtus.    Fcetal  Malaria  ;  Observations  ;  Pathogenetic  Possibilities. 

The  transmitted  disease.s  of  the  fcetu.s  constitute  the  most  interestuig 
group  of  antenatal  morbid  states.  Theii'  interest  dejiends,  in  the  first 
place,  upon  the  varied  and  intricate  relations  which  are  or  miLj  be 
established  between  the  maternal  and  foetal  organisms  through  them 
and  as  a  result  of  them :  in  no  physiological  or  pathological  labor- 
atory could  more  elaliorate  or  instructive  experiments  be  devised 
and  carried  through  than  are  to  be  witnessed  in  the  utertis,  when 
the  mother  is  the  subject  of  a  malady  which  is  known  to  be  trans- 
missible. In  the  second  place,  their  interest  depends  upon  the 
possibilities  of  successful  therapeutics  which  they  present ;  when  the 
cause  of  a  disease  is  known,  and  when  the  diagnosis  of  its  occurrence 
is  not  outside  the  bounds  of  possibility,  the  chances  of  successful 
treatment,  preventive  and  curative,  are  much  increased.  To  some 
extent  it  may  be  said  that  the  etiology  of  the  transmitted  fct'tal 
diseases  is  within  our  knowledge,  and  their  diagnosis  not  altogether 
outside  our  grasp ;  with  perseverance  and  skill  their  treatment  will 
yet  be  hopefully  undertaken  bj^  the  well-informed  pliysician.  There 
are  other  reasons  why  tlie  transmitted  ftetal  diseases  appeal  more 
directly  to  us  than  the  idiopathic  maladies ;  some  of  these  will 
emerge,  as  the  consideration  of  the  suliject  is  proceeded  with  ;  in  the 
meantime  let  us  take,  as  the  first  type  of  this  group, /(«<«/  variola. 

Variola    in    the    Foetus. 

In  the  first  separate  work  mi  diseases  of  tlie  tVetus  (GG),  tlio 
author,  Diittel,  writes :  "  rrinmni,  autem,  deprehendimns  morbuni 
variolum,  quo  gravida  corripitur  saepius  transire  in  ipsum  ftetum." 
and  proceeds  to  gather  together  the  cases  of  fretal  variola  which  had 
up  ti)  that  time  (1702)  been  reported.  There  were  not  many  of 
them ;  Ijut  in  the  nundjcr,  it  is  interesting  to  note,  were  instances  of 
foetuses  with  smallpox,  the  ofl'spring  of  women  who  had  themselves 
escaped  the  malady,  but  had  lieen  in  contact  with  cases  of  it.  Thus 
early  was  it  observed    that    tlie    infection  might    j)ass    througli  the 


F(ETAL   \'ARIOLA  180 

maternal  organism  to  the  fetal  withimt  manifesting  itself  in  tlie 
former.  Eeference  was  also  made  to  the  case  of  a  variolous  mother 
whose  infant  was  born  with  no  signs  of  smallpox ;  but  in  this 
instance  the  infant  died  before  the  malady  had  time  to  develop.  It 
may  be  concluded  that,  prior  to  1600,  the  occurrence  of  variola  in 
the  foetus  was  hardly  suspected,  and  was  even  denied,  as  is  seen  from 
the  statement,  "  Dum  fretus  est  in  utero,  non  ei  accedere  variolos 
nee  morbillos  " ;  but  with  the  seventeentli  century  came  the  records 
of  undoubted  cases,  and,  as  has  been  seen,  at  the  beginning  of  the 
eighteenth,  Diittel  was  able  to  enumerate  quite  a  number  of  them. 
As  late,  however,  as  the  close  of  the  eighteenth  century,  the  birth  of 
such  a  ftetus  was  regarded  as  somewhat  of  the  nature  of  a  wonder,  for 
Lynn's  paper  read  at  the  Eoyal  Society  (London)  in  1786  was 
entitled,  "  The  singular  case  of  a  Lady  who  had  the  Smallpox  during 
pregnancy,  and  who  communicated  the  same  disease  to  the  Foetus." 
I  have  met  with  traces  of  a  belief  in  the  immunity  of  the  foetus  from 
smallpox  among  the  laity  even  at  the  itresent  time.  From  the  now 
very  large  number  of  published  cases  of  foetal  variola  it  is  easy  to 
obtain  some  idea  of  the  pathogenetic  possibilities,  when  a  pregnant 
woman  develops  smallpox  or  comes  into  contact  with  a  case  of  it. 
Let  me  state  some  of  these  possibilities. 

When  a  pregnant  woman  is  attacked  by  smallpox,  it  does  not 
necessarily  follow  that  her  infant  will  lie  Ijorn  showing  the  eruption 
on  its  skin.  It  may  be  born  alive  with  no  sign  of  variola,  and  may 
die  soon  afterwards,  or  may  li^-e  and  not  develop  the  disease ;  in  the 
latter  case,  it  would  appear  that  it  is  possessed  of  an  antenatal 
immunity  from  variola,  which  persists  in  postnatal  life.  It  may  also 
be  born  dead,  having  died  in  utero,  from  the  high  temperature  or 
some  other  cause,  liefore  the  disease  had  time  to  show  itself  in  the 
form  of  the  distinctive  eruption.  In  fact,  it  must  be  regarded  as  the 
exception  and  not  as  the  rule  to  meet  with  variola  in  the  stage  of 
eruption  at  the  time  of  birth.  There  is  great  need  for  further  and 
more  accurate  investigation  of  the  infants,  alive  and  dead,  that  are 
the  offspring  of  variolous  mothers,  and  yet  show  no  external  signs  of 
variola.  It  may  be  found  that,  although  they  have  not  the  pustules 
and  other  external  indications  of  smallpox,  yet  they  may  have 
suftered  in  other  ways :  for  instance,  there  may  be  traces  of  the  eruption 
on  mucous  surfaces ;  or  the  nutrition  may  have  been  interfered  with, 
and  an  atrophic  state  produced  which  persists  after  birth  and  pre- 
disposes to  infantile  diarrhoea,  etc. ;  or  there  may  have  been  secondary 
infection  with  streptococci  and  staphylococci  (Auche,  Bull.  Soc. 
d'anat.  et  physiol.  de  Bordeaux,  xiii.  278,  1892) ;  or  the  placental 
tissues  may  have  become  diseased,  and  foetal  death  occurred.  From 
our  knowledge  of  other  transmissible  maladies,  we  are  justified  in 
lielieving  that  the  poison  of  variola,  entering  the  ftctus  by  the 
umlnlicus,  may  cause  lesions  in  the  organs  along  the  placental  route 
of  invasion  without  affecting  the  skin. 

When,  however,  tlie  foetus  shows  marked  external  signs  of  small- 
pox, several  clinical  types  may  be  met  with.  Thus,  the  mother  may 
pass  through  a  slight  attack  of  modified  variola,  her  pregnancy  may 


190  AN  ri-.NAr.U,    l'.\ril()I.()(iV    and    ll^(iIKNK 

go  on  to  the  full  leiiii,  uiul  :i  living  iufaut  be  born  eoveied  with  a 
great  or  a  small  number  of  pustules,  or  with  scars,  or  with  simple 
papules  which  have  not  yet  suppurated.  Again,  the  pregnancy  may 
be  interrupted,  and  the  fu'tus  l)e  liorn  prematurely,  showing  the 
eruption  in  one  or  other  of  its  stages,  or  developing  the  exanthem 
within  a  few  hours  or  days  of  liirtli.  Yet  again,  the  mother  may  die 
from  confluent  or  hiemorrhagic  smallpox,  and  the  tVetus  be  removed 
post-mortem  from  her  uterus  and  be  found  bearing  the  evident  signs  of 
the  malady.  Apparently  the  f(ptus  is  susceptible  to  variola  at  any 
stage,  for  a  case  at  the  third  month  has  been  reported,  and  there  are 
observations  at  almost  all  ages  after  that  up  to  the  fidl  term.  An 
interesting  complication  is  introduced  into  the  clinical  types,  when 
the  uterus  contains  not  one  but  two  ftctuses ;  in  one  of  the  recorded 
cases  both  the  twins  suffered  from  variola ;  in  another  case,  one  was 
affected  while  the  other  had  evidently  escaped ;  and  in  a  third  case, 
although  both  fcetuses  showed  the  eruption,  one  exhibited  many 
pustules  (sixty-five  in  all)  while  the  other  had  only  a  few  (six).  In 
these  plural  pregnancies  Iwth  the  ftetal  membranes  and  the  placenta 
were  generally  double,  but  in  one  remarkable  instance,  reported  by 
Chantreuil  {Gaz.  d'lwp.,  xliii.  173,  1870)  the  placenta  was  composed 
of  a  single  mass,  although  there  were  two  chorions  and  amnions. 
Chantreuil's  case  was  also  noteworthy,  for  the  reason  that,  while  one 
twin  evidently  had  variola,  neither  the  other  twin  nor  the  mother 
suffered  from  it,  a  striking  example  of  the  pathological  independence 
of  the  unborn  infant,  both  as  regards  his  mother  and  his  brother 
or  sister  in  utero.  It  is  possible  to  account  for  such  a  case  as  that 
just  referred  to  ;  but  what  is  to  be  said  about  the  explanation  which 
Legros  {Gaz.  mcd.  dc  Far.,  3.  s.,  xx.  493,  1865)  offers  in  connection 
with  the  following  record  ?  A  woman  gave  birth  to  a  five  months 
foetus  showing  the  eruption  of  smallpox;  she  had  not  herself  had 
smallpox ;  but  the  father  of  the  child  was  in  the  stage  of  con- 
valescence from  variola  when  conception  took  place.  Could  the 
infection  have  remained  latent  in  the  embryo  and  then  in  the  fo'tus 
until  nearly  five  months  of  intrauterine  life  had  elapsed  ?  This 
possibility  has  been  affirmed  for  syphilis  and  malaria,  but  in  this 
case  one  is  tempted  to  ask  whether  the  fectus  was  really  suttering 
from  variola  ?  At  the  same  time,  it  may  be  that  the  incubation 
period  in  the  fietus  is  different  from  that  in  the  adult,  for  in  the  case 
reported  by  Laurens  {Bull.  Soc.  anat.  de  Par.,  xliii.  184,  1868)  tlie 
mother  had  smallpox  early  in  her  pregnancy,  and  two  and  a  half 
months  later  aborted  of  a  fietus  with  the  eruption  well  marked.  In 
order  to  complete  this  survey  of  the  chief  clinical  po.ssibilities  of 
ftetal  variola,  it  may  be  added  that  the  disease  may  perhaps  be 
acquired  by  the  infant  during  his  transit  through  the  maternal 
passages,  or  very  soon  thereafter;  but  this  can  hardly  be  described  as 
ivvLQ  fatal  smallpox. 

Eeference  has  already  been  made  in  the  previous  chapter  to  the 
symptomatological  i)eculiarities  of  variola  as  it  occurs  in  the  unborn 
infant ;  but  certain  details  may  profitably  be  repeated  here,  and  some 
new  points  added. 


Fig.  28. — Laurens'  Case  of  Smallpox  in  tlie  Fcetus 


larcot. 

Laurens 

15 

1 

23 

22 

19 

30 

8 

— 

16 

15 

12 

20 

192  ANTF.NATAI.    I'A  THOLCXiV    AM)    HYCUKNE 

Tlie  eruption  has  a  distriluition  wliicli  may  best  be  desciilied  as 
irregular ;  tlie  order  of  aiipearance  is  also  irregular.  Tlie  spots  are 
usually  few  in  num1)er  (12-100),  and  the  variola  is  therefore  of  the 
discrete  type;  rarely  they  are  many,  and  the  confluent  type  is 
produced ;  even  the  lucmorrliagic  form  of  eruption  has  been  met  with 
(Cless,  JA'rf.  C'or.-Bl.  <1.  wiirt/cmh.  drztl.  Ver.,  xxxvi.  '2'i,  18GG).  Below 
will  be  found  in  a  tabular  form  the  number  of  s])ots  and  their  dis- 
tribution in  two  cases  of  fu'tal  variola,  one  reported  by  Charcot  {Cumpt. 
rend.  Soc.  de  hioL,  v.  88,  1853)  and  the  other  (Fig.  28)  by  Laurens 
(These,  Paris,  1870):— 

Face  .... 

Scalp  and  back  of  neck 
Thorax  and  abdomen 
Scrotum  and  buttocks 
Upper  limbs 
Lower  liml)S 

93  88 

The  pustules  vary  in  size  from  1  to  9  mm.  in  diameter ;  they  have 
the  same  shape  as  in  the  adult,  and  show  umbilication,  and  they  run 
through  the  same  stages  of  macules,  papules,  vesicles,  and  pustules. 
They  have  a  white  or  pale  yellow  colom',  and  contain  clear  yellow  or 
slightly  opaque  fluid,  and  sometimes  pus.  Suppuration,  however, 
is  not  a  common  feature,  and  there  is  little  or  no  crust  formation ; 
the  eruption  resembles  that  seen  on  mucous  surfaces  in  the  adult. 
The  pustules  are  surrounded  by  a  red  areola ;  they  are  not  limited  to 
the  skin,  but  have  been  found  on  the  mucous  membranes  of  the  mouth, 
pharynx,  and  stomach,  and  even  on  the  visceral  pleura  (E.  Hue,  7'hese, 
Paris,  1862).  The  microscopical  appearances  of  the  eruption  have 
been  described  by  Charcot  {Compt.  rend.  Soc.  dc  hioL,  iii.  39,  1851) : 
"  Une  alteration  eavitaire  du  corps  muqueux  de  Malpighi." 

With  regard  to  the  stages  of  the  fever  iu  utero,  it  seems  to  I)e 
generally  believed  that  the  incubation  period  varies  within  wide 
limits  (Margoulieff,  TVft'sc,  Paris,  1889);  there  is  some  evidence  that 
it  may  occupy  the  same  time  in  mother  and  fcptus  and  run  simul- 
taneously, but  there  is  also  evidence  that  it  may  begin  in  the  fcetus 
only  when  the  stage  of  eruption  has  been  reacheil  in  the  mother,  and 
there  is  even  reason  to  suppose  that  the  incubation  may  be  lengthened 
to  four  or  five  weeks.  The  stage  of  invasion  is  marked,  sometimes  at 
least,  by  exaggerated  fcetal  movements,  and  possibly  by  maternal 
malaise ;  the  stage  of  suppuration,  when  it  occurs,  is  no  doubt 
signalised  by  an  aggravation  of  the  mother's  symptoms :  and  the 
stage  of  desiccation  possibly  follows  a  course  ditlering  in  some  details 
from  that  seen  when  the  pustules  are  under  the  influence  of  the  air. 
In  fcrtal  as  in  adult  variola  complications  are  met  with,  and  cases 
have  been  reported  of  periostitis  and  necrosis  of  the  tibia  and  of 
staphylomatic  exophtlialmia  iu  infants  who  have  suttered  from 
exanthem  in  utcvo  (T.  Mejan,  Joxirn.  dc  mi'd.,  chir.,  et  i^harm.,  i.  145, 
1803). 


FCETAL   VARIOLA  103 

It  need  hardly  be  added  that  smallpox  as  it  occurs  in  the  fwtus 
is  the  same  disease  as  that  met  with  in  the  adult ;  but,  as  a  matter 
of  fact,  it  has  been  proved  to  be  so  by  the  occurrence  of  infection,  and 
by  the  possibility  of  inoculating  another  individual  with  the  malady 
by  means  of  the  matter  from  the  pustules  of  the  new-born  infant 
(E.  Jenner,  Med.-Cliir.  Trans.  Lond.,  i.  271,  1815).  Further,  infants 
who  have  suffered  from  the  disease  in  utero  have  been  found  to  he 
refractory  Ijoth  to  inoculation  and  to  vaccination. 

The  antenatal  diagnosis  of  fcetal  variola  has  not  been  made ;  but 
there  is  no  reason  why  it  should  not  be  provisionally  made  when 
smallpox  is  met  with  in  a  pregnant  woman,  and  when  there  is  the 
distinct  history  of  exaggerated  fcetal  movements  corresponding  in 
time  with  the  stage  of  invasion  in  the  mother.  After  the  infant  is 
born  there  ought  to  be  no  difficulty  in  recognising  the  disease,  save 
perhaps  in  the  cases  in  which  the  mother  has  escaped,  but  even  in 
these  the  history  of  exposure  to  infection  and  the  nmljilication  of  the 
pustules  ought  to  suffice.  Neonatal  pemphigus  and  ecthjinatous 
syphilis  neonatorum  present  resemblances,  but  not  so  great  as  to 
mislead  the  careful  observer  who  is  aware  of  the  possibility  of 
smallpox  attacking  the  fcctus  in  utero  without  at  the  same  time 
affecting  the  mother.  It  is  impossible  to  state  what  is  the  intra- 
uterine death-rate  for  foetal  variola.  Possibly  the  fate  of  the  foetus 
is  determined  chiefly  hj  the  degree  of  severity  of  the  maternal 
malady,  and  by  the  occurrence  or  non-occurrence  of  premature 
labour,  and  not  so  much  by  the  type  of  the  fever  by  which  it  is 
affected.  Mauriceau,  who  by  his  writings  made  conspicuous  addi- 
tions to  the  knowledge  of  fcetal  pathology,  was  himself  an  instance 
of  a  good  recovery  from  foetal  smallpox.  That  the  foetus  recovers 
from  intrauterine  A'ariola  need  not  cause  much  surprise,  when 
it  is  remembered  that  its  surroundings  are  the  very  ones  that  the 
physician  would  choose  for  his  variolous  patients,  including  as  they 
do,  protection  from  light  and  the  continual  bathing  of  the  whole  body 
in  a  warm  fluid  medium  of  practically  constant  temperature.  But, 
on  the  other  hand,  the  presence  of  smallpox  in  the  unborn  infant 
may  increase  the  gravity  of  the  maternal  prognosis,  for  it  is  probable 
that  the  mother's  organs,  and  especially  her  kidneys,  may  receive 
from  the  morbid  foetus  such  a  flood  of  pathological  products  as  to  be 
most  prejudicially  affected  thereby. 

The  treatment  of  variola  in  postnatal  life  is  or  ought  to  be 
prevention,  and  nothing  else  ought  to  Ije  necessary.  In  vaccination 
we  have  a  sure  means  of  preventing  this  malady,  and  this  means 
ought  always  to  be  used.  Is  there  any  reason  why  a  different 
standard  of  treatment  should  be  applied  to  the  unborn  infant  ?  It 
has  been  stated  that,  supposing  the  foetus  has  taken  smallpox  in 
utero,  we  may  with  some  degree  of  confidence  leave  it  to  Nature  to 
eftect  a  cure,  our  chief  duty  being  to  prevent  premature  expulsion  of 
the  little  patient  from  his  hospital :  but  are  there  any  means  that 
can  be  adopted  to  lessen  the  risk  of  his  developing  variola  in  utero  ? 
In  other  words,  is  intrauterine  vaccination  possible  ?  The  answer 
to  this  question  demands  a  separate  paragraph. 
13 


194  ANTENATAL    I'ATlIOI.OCiV    AND    HYGIENE 


Vaccinia  in  the  Fcetus. 

The  infant  of  a  woman  who  has  had  smallpox  in  her  pregnancy 
may  be  insusceptible  to  vaccination.  A  case  of  this  kind  occurred 
in  my  dispensary  practice  some  years  ago  :  a  woman  who  liad  during 
her  gestation  a  mild  attack  of  ^'ariola,  gave  jjirth  ten  weeks  after 
lier  recovery  to  a  child,  who  was  vaccinated  on  several  occasions 
but  always  without  success ;  she  herself  had  good  vaccination 
marks,  which  no  doubt  accounted  for  the  mildness  of  her  attack. 
There  seemed  to  be  no  evidence  that  the  child  had  had  variola  in 
utero ;  if  he  had,  the  recovery  must  have  been  absolutely  perfect,  for 
no  traces  were  visible.  It  may  be  supposed,  perhaps,  that  lie  was 
immune  against  both  smallpox  and  vaccination  as  an  idiosyncrasy. 
It  seems,  however,  to  be  more  reasonalile  tn  believe  that  he  had  been 
protected  by  the  placental  barrier,  or  some  other  means,  from  the 
maternal  disease,  but  had  at  the  same  time  got  minimum  doses  of 
the  toxine  and  been  rendered  immune  against  variola,  and  therefore 
refractory  to  vaccination.  Whether  this  be  the  correct  explanation 
of  the  occurrence  or  not,  the  case  raises  the  question  of  the  possibility 
of  protecting  the  fcetus  by  vaccinating  the  mother.  If  a  mother 
suffering  from  smallpox  can  confer  immunity  on  her  infant  in 
utero,  without  the  latter  showing  any  external  signs  of  variola,  can 
she  by  undergoing  vaccination  also  give  this  immunity  without  the 
child  exhibiting  vaccination  marks  ?  In  a  sentence,  can  we  give 
the  unborn  infant  immunity  against  smallpox  l)y  vaccinating  the 
mother  during  her  pregnancy,  and  if  so,  is  the  result  brought  about 
by  the  vaccination  of  the  ftetus  or  by  the  transmission  to  it  of 
an  acijuired  property  l;iy  the  mother  ? 

Many  observations  have  been  made  upon  tlie  vaccination  of  the 
pregnant  woman.  During  an  epidemic  of  smallpox,  pregnant  women, 
like  the  other  members  of  the  connnunity,  are  revaccinated,  to  save 
tliem  from  the  disease ;  and  there  are  therefore  many  opportunities 
of  testing  whether  their  infants  are  afterwards  refractory  to  vaccina- 
tion or  not.  It  must  at  once  be  admitted  that  they  are  not  invari- 
ably refractory  to  subsequent  vaccination ;  but  it  may  also  be 
claimed  as  clearly  proven  by  statistics,  that  many  of  them  are 
insusceptible,  and  that  the  immune  percentage,  so  to  speak,  is  larger 
than  can  he  accounted  for  Ijy  idiosyncrasy  or  accidental  causes. 
According  to  some  observers,  the  percentage  of  refractory  infants 
is  32  ;  according  to  others  it  is  as  high  as  80  per  cent. ;  and  among 
recent  authorities,  Piery  (Lyon  niM.,  xciv.  p.  37,  1900),  from  his 
own  results  and  those  of  others,  gives  58  per  cent,  as  the  average. 
Hermann  Palm  (Arch.  f.  Gynack,  Ixii.  348,  1901),  however,  giv(  ^ 
a  mucli  lower  pro])ortion  of  refractories.  It  will,  I  think,  ln' 
safe  to  accept  one  t'lctus  in  three  as  the  proportion  protected  by 
vaccination  of  the  mother  in  the  second  half  of  pregnancy.  From 
what  we  know  of  the  laws  of  placental  transmission,  this  is  what 
was  to  be  expected.  If  we  compare  the  transmission  of  smallpox 
with  that  of  vaccinia,  we  are  not  entitled  to  expect  that  the  latter 


VACCINIA   IX   THE   FGETUS  195 

will  pass  from  mother  to  fcetus  oftener  than  the  former.  But,  it 
may  be  asked,  are  they  comparable  ?  I  think  they  are  :  but  it  is 
necessary  to  remember  that  there  are  details  in  which  they  differ. 
An  infant  lias  never  lieen  liorn  carrying  a  vaccination  pustule  upon 
its  skin,  as  the  result  of  the  vaccination  of  the  mother ;  but,  similarly, 
an  infant  has  never  been  born  with  the  primary  sore  of  syphilis 
upon  its  genital  organs.  The  point  of  contact  of  mother  and  foetus 
is  in  the  placenta  and  not  on  the  foetal  cutaneous  surface.  If 
a  vaccination  mark  or  a  primary  sore  occur  in  antenatal  life  at  all, 
it  is  to  be  looked  for  in  all  probability  in  the  placenta.  To  return, 
now,  to  the  original  question  with  which  this  paragraph  began, 
How  does  maternal  vaccination  in  pregnancy  protect  the  fcetus  ? 
It  may  be  that  there  is  a  direct  transmission  of  the  antitoxine 
which  is  elaborated  in  the  maternal  tissues  to  the  foetus;  but 
it  is  more  prolialjle  that  the  immimising  agent,  whatever  it  may 
be,  passes  to  the  foetus  and  acts  upon  its  tissues  and  fluids,  and 
that  these  then  elaborate  the  antitoxine.  This,  at  any  rate,  is  the 
view  advanced  by  Lop  {TMsc,  Paris,  189r>),  and  it  has  much  to 
commend  it. 

There  is  reason  to  believe  that  the  protection  against  smallpox 
which  a  fcetus  gets  from  the  vaccination  of  the  mother  during  her 
pregnancy  does  not  last  long;  six  months  has  been  stated  as  the 
probable  period  of  protection.  In  this  respect  it  is  comparable,  as 
has  been  pointed  out  by  Bar,  Beclere,  and  others,  to  the  immunitj^ 
given  hy  immunising  serums  rather  than  to  that  conferred  upon 
the  infant  after  birth  by  arm  vaccination.  The  practical  consequence 
of  this  conclusion  is,  that  it  is  necessary  to  vaccinate  all  new-born 
infants  whether  their  mothers  have  been  vaccinated  in  pregnancy 
or  not. 

It  must,  in  conclusion,  be  pointed  out  that  it  is  possible  that  an 
infant  may  obtain  immunity  against  smallpox  (as  shown  by 
refractoriness  to  vaccination),  in  another  way  than  that  referred  to 
above :  it  may  he  rendered  immune  while  still  in  the  mother's 
ovary.  Thus,  there  is  reason  to  believe  that  sometimes  the  vaccina- 
tion of  the  mother  during  her  childhood  may  confer  immunity  npon 
her  future  infants:  Piery  {loc.  cit.)  found  that  of  forty-four  women 
who  were  vaccinated  without  success  in  their  pregnancies,  presum- 
ably on  account  of  earlier  successful  vaccination,  thirty-one  gave 
bii'th  to  infants  that  were  refractory  to  vaccination;  while  of  five 
women  vaccinated  successfully  in  the  last  month  of  pregnancy,  on 
account  of  absence  of  pre-existing  immunity,  only  one  transmitted 
immunity  to  her  infant.  This  "  hereditary "  mode  of  transmission 
of  immunity  from  mother  to  infant  is  more  closely  related  to  the 
experimentally  induced  immunity  against  such  microbic  conditions 
as  the  pyocyanic  disease  {vide  Charrin  and  Gley,  Arch,  de  fhydol. 
norm,  et  path.,  5  s.,  viii.  225,  1896)  than  to  the  matters  at  present 
under  discussion ;  it  will  be  referred  to  later.  The  practical 
conclusion  is,  that  it  is  wise  in  the  presence  of  an  epidemic  of 
smallpox  to  revaccinate  a  pregnant  w-oman  for  the  sake  of  her 
unborn  infant,  even  if  not  for  her  own. 


196  ANTENATAL    I'ATIIOLOCY    AND    HYGIENE 


Foetal   Measles,   Scarlet  Fever,   Erysipelas,   etc. 

I  have  chosen  f«>tal  variola  as  the  type  of  tlie  exanthemata  that 
may  be  met  with  in  intrauterine  life,  for  many  cases  have  been 
recorded,  and  therefore  most  of  the  clinical  and  pathological 
varieties  have  Ijeen  observed.  The  otlier  eruptive  fevers,  however,  if 
not  so  well  known,  are  at  any  rate  not  unknown  in  the  foetus  ;  and  the 
investigation  of  some  of  them  has  brought  out  new  facts  with  regard 
to  the  jiathological  intertwining  of  the  maternal  and  fo'tal  lives. 

Of  foital  measles  I  have  met  with  and  pnbli.shed  a  case  (56). 
The  mother  developed  an  attack  of  measles  for  the  first  time  at 
the  sixth  month  of  her  first  pregnancy ;  the  disease  ran  its  ordinary 
course,  but  during  the  stage  of  decline  of  the  eruption  the  fcptus 
was  prematurely  expelled  and  soon  died ;  and  the  mother  made  a 
good  recovery.  The  fwtus,  a  male,  showed  a  large  number  of  spots 
of  morbilli  on  the  back,  a  few  on  the  lower  limbs  near  the  ankles, 
and  one  or  two  on  the  face ;  some  stringy  mucus  was  adherent  to 
the  nose  and  mouth.  He  was  somewhat  poorly  nourished.  At  the 
time  when  I  published  this  case  (189.3),  I  gathered  together  from 
literature  some  twenty  recorded  examjdes  of  fa'tal  measles.  Among 
these  was  the  case  quoted  by  Squire  {Trans.  Obsf.  Soc.  Loud.,  xvii. 
146,  1876)  from  the  "Sydney  Pa^^ers":  "Lady  Sydney  was  sickening 
for  measles,  when,  on  third  day,  with  severe  cough  and  full  rash, 
she  was  brought  to  bed  of  a  goodly  fat  son ;  the  child  was  also  full 
of  the  measles,  mostly  in  the  face,  yet  it  sucked  the  nurse  as  well  as 
any  child  could."  So  far  as  could  be  judged  from  the  chuical 
details  given  in  the  twenty  cases,  it  seemed  that  the  infection  of 
mother  and  foetus  must  have  been  simultaneous,  for  the  eruption 
on  the  latter  at  the  time  of  birth  corresponded  in  character  with 
that  then  exhibited  liy  the  mother.  No  instance  has  been  placed 
on  record  of  a  f(Ptus  sutfering  from  measles,  the  mother  escaping, 
although  having  been  subject  to  infection ;  but  the  small  number  of 
known  cases  does  not  permit  us  to  draw  conclusions  regarding  this 
and  other  pathogenetic  possibilities. 

Of  fcetal  scarlet  fever  I  have  also  met  with  one  case,  tliat  reported 
by  Dr.  Milligan  and  myself  (59).  The  mother  was  a  primipara,  21 
years  of  age,  who  began  to  suffer  from  symptoms  suggesting  scarlet 
fever  about  the  seventh  month  of  her  pregnancy ;  from  the  state  of 
the  tongue,  the  appearance  of  the  rash,  and  the  high  temperature,  as 
well  as  from  the  distinct  history  of  exposure  to  contagion,  the 
diagnosis  was  fully  made;  the  infant  was  born  prematurely  and  with 
considerable  hicmorrhage  in  the  third  stage.  Within  twenty-four 
hours  of  its  birth  it  was  noticed  that  the  child  was  covered  with  a 
red  rash  and  that  some  of  the  glands  of  the  neck  were  enlarged; 
the  skin  was  hot  to  the  touch,  and  the  tongue  was  bright  red,  although 
not  coated  as  in  .scarlet  fever  in  later  childhood.  The  diagnosis  of 
scarlet  fever  developed  in  intrauterine  life  was  made,  and  in  about 
a  week  afterwards  both  mother  and  infant  passed  through  the  stage 
of  desquamation.     Not   more   than  twenty  well-authenticated  cases 


FCETAL  ERYSIPELAS  197 

of  scarlet  fever  in  the  fretns  have  been  recorded ;  but  it  may  occur 
oftener  than  is  supposed,  for  the  diagnosis  is  uot  easy,  and  the 
eruption  is  apt  to  Ije  confounded  with  the  physiological  erythema 
and  desquamation  of  the  new-born.  In  the  instances  which  have 
been  noted,  the  infection  in  mother  and  foetus  would  seem  to  have 
been  practically  simultaneous.  Leale's  case  was  a  very  clearly 
established  and  typical  one  {Med.  News,  xliv.  635,  1884). 

Although  the  intrauterine  transmission  of  erysipelas  is  to  be 
regarded  as  possible  and  even  probal^le.  it  is  a  striking  fact  that  so 
few  cases  have  been  reported  in  which  that  malady  was  noted  in  the 


Fig.  29. — Section  of  Tricuspid  Valve  of  Heart :  a,  vegetation  upon  valve  ;  h,  tri- 
cuspid valve  ;  c,  newly  formed  vessel,  indicated  by  micro-organism  ;  d,  mycotic 
thrombi ;  e,  infiltration  of  leucocytes. 

infant  at  liirth.  Even  inE.  Kaltenbach's  ol^servation  {CcntrlU.f.Gyndk., 
viii.  689,  1884)  and  in  Stratz's  {ibid.,  ix.  213,  1885)  the  diagnosis 
could  not  be  regarded  as  certain,  for  the  bacteriological  confirmation 
was  wanting.  Lebedeff's  case  {Ejcncd.  Uin.  fjaz.,  St^Petersb.,  vi.  285, 
1886)  was  more  completely  demonstrated.  It  may  be,  however, 
that  the  foetal  environment  and  the  peculiarities  of  fa?tal  physiology 
prevent  the  development  of  the  characteristic  cutaneous  and  sub- 
cutaneous manifestations  of  erysipelas ;  it  may  also  be  that  foetal 
erysipelas,  when  it  has  occurred,  has  been  classified  simply  as  a 
well-marked    instance    of    neonatal    erythema    and    desquamation. 


198  ANTENATAL   PATHOLOGY   AND   HYGIENE 

Kecent  iiivestinatinns  on  tliis  subject  seem  to  show  that  erysipelas 
can  be  and  pnibitbly  often  is  transmitted  from  mothei'  to  fn'tiis,  but 
takes  on  pathological  characters  in  the  latter  which  ditl'er  from  tlmsc 
seen  in  the  former.  The  streptococci  apparently  sometimes  pass  the 
placental  barrier  and  invade  the  foetal  tissues  l)y  the  umbilical 
avenue  of  entrance ;  they  nuist  then  reach  first  the  organs,  such  as 
the  liver  and  heart,  which  lie  directly  in  tlieir  path ;  and  there  is 
evidence  to  show  that  they  may  set  up  morliid  changes  in  these  parts 
without  att'ectin.!;'  the  skin  or  sulicutaneous  tissue  at  all.  The 
interesting  and  important  observation  made  by  E.  IJidone  (Tcratolfyin, 
i.  182,  1894)  has  been  incidentally  referred  to  in  the  preceding 
chapter.  It  was  that  of  a  pregnant  woman,  a  primipara,  who  was 
attacked  by  facial  erysipelas  about  the  beginning  of  the  ninth  moutli : 
after  having  given  birth  to  a  male  infant,  she  died  in  the  ])uerperium 
from  septic  peritonitis  and  endometritis.  The  infant  died  about 
nineteen  hours  after  birth,  and  at  the  autopsy  vegetations  were  found 
on  both  the  tricuspid  and  mitral  valves,  but  specially  on  the  former, 
along  with  incipient  glomerulo-nephritis  ;  numerous  streptococci  were 
found  iu  the  spleen,  lungs,  kidneys,  but  more  particularly  in  the 
vegetations  on  the  cardiac  valves  (Fig.  29);  and  cultures  and  in- 
oculations showed  that  the  micro-organism  was  the  streptococcus  nf 
erysipelas.  In  this  case  the  streptococcic  endocarditis  on  the  auriculn- 
ventricular  valves  seems  to  have  taken  the  place  of  the  skin  lesinus 
of  erysipelas,  for  it  is  apparently  clear  that  the  infection  ])asseil 
through  the  placenta  from  mother  to  fcetus.  The  maternal  disease, 
then,  led  to  the  develo]iment  of  a  pathological  condition  in  the  fo'tus, 
which  was  the  same  in  its  microbic  nature  but  differed  in  its  manifesta- 
tions. It  may  be  that  what  has  been  found  in  relation  to  erysi]jelas 
may  apply  to  other  transmissible  diseases;  the  mother  may  show  the 
typical  manifestations,  while  the  foetus  suffers  from  a  modified  malady. 
Moncorvo's  suggestion  relating  to  congenital  elephantiasis  and  the 
streptococcus  will  he  considered  later. 

Along  with  ftetal  measles,  scarlatina,  and  erysipelas,  I  may  place 
foetal  parotitis,  influenza,  and  pertussis.  There  are  scanty  records  of 
cases  in  which  mumps  and  whooping-cough  seem  to  have  been  present 
at  birth ;  and  of  congenital  infliienza  there  are  several  instances,  and 
I  have  myself  noted  at  least  three  (20).  Cases  of  relapsing  fever 
(E.  Albrecht,  IFiai.  mrcl.  BL,  vii.  738, 1884  ;  ,SY.  Pder^h.  mcd.  JVclnischr., 
i.  129,  1894;  Mamuroffski,  ihid.,  Bdla(ic,\\  10,  1896);  and  of  yellow 
fever  (J.  Jones,  Mcd.  Times  and  Gaz.,  i.  for  1874,  p.  5;  C.  Fiulay, 
£din.  Mcd.  Journ.,  xl.  416,  1894),  have  lieen  reported;  and  cholera 
in  the  new-born  infant  has  been  met  with  (J.  C.  Lucas,  Trans.  Obst. 
Soc.  Lond.,  xxi.  250,  1880  :  Tizzoni  and  Cattani,  Ccntrlhl.  f.  d.  med. 
Wisscnsch.,  xxv.  131,  1887;  E.  Yitanza,  Eiforma  med.,  vi.  272,  278, 
284,  290,  1890).  Varicella  in  utero  is  not  unknown ;  J.  Grindon 
(Journ.  Cutan.  and  Gcn.-Urin.  Dis.,  xix.  237,  1901)  has  recorded  an 
apparent  case,  although  the  cutaneous  lesions  in  the  infant  were  not 
typically  vesicular.  Foetal  typhoid  is  a  morbid  entity  which  has 
only  recently  lieen  recognised ;  and,  since  it  presents  several  features 
of  special  interest,  deserves  a  more  detailed  description. 


FCETAL  TYPHOID  199 


FcEtal  Typhoid  Fever. 


]^>efore  the  recoguitiou  of  the  baciUus  of  typhoid  fever,  few  cases  had 
been  met  with  iu  the  foetus ;  the  reasons  were  obvious,  for  the 
external  appearances  of  the  disease  were  such  as  might  easily  pass 
unobserved,  and  the  internal  pathological  conditions  were  seldom 
looked  for.  Fnrtlier,  it  was  almost  to  be  expected  that  the  intestinal 
appearances  which  are  so  diagnostic  in  typhoid  in  the  adult,  would  l)e 
little  if  at  all  marked  in  the  fetus.  Nevertheless,  two  or  three  cases 
of  foetal  typhoid  ending  fatally  soon  after  birth  were  reported  prior 
to  the  discovery  of  the  causal  bacillus  (Charcellay,  Arch.  gi^n.  clc  mM., 
3  s.,  ix.  05,  1840)  ;  in  these  the  ulceration  of  the  Peyerian  patches 
in  the  intestine  was  observed,  as  was  enlargement  of  Brunner's  glands. 
"VMien  we  remember  the  characters  of  the  distribution  of  pathological 
lesions  iu  the  firtus,  due  to  physiological  peculiarities  and  the  avenue 
of  entrance  of  the  infection,  it  need  not  be  a  source  of  wonder  that  so 
few  cases  of  typhoid  fever  with  intestinal  lesions  have  been  met  with  ; 
such  cases  must  be  very  rare.  There  is  good  reason  to  believe  that 
foetal  typhoid  is  commonly  unaccompanied  by  intestinal  ulceration ; 
and  it  must  not  be  forgotten  that  even  adult  typihoid  sometimes  shows 
the  same  peculiarity.  The  discovery  of  the  pathogenic  organism  of 
typhoid  made  it  possible  to  diagnose  with  some  degree  of  confidence 
cases  of  enteritis  without  intestinal  lesions ;  and  the  result  of  this 
bacteriological  discovery  was  immediately  manifest  in  the  publication 
of  a  considerable  numljer  of  instances  of  fcctal  typhoid  fever.  One 
of  the  first,  if  not  the  very  first  certain  case,  was  that  reported  by 
C.  J.  Eberth  (Fortschr.  d.  Med.,  vii.  161,  1889),  for  the  evidence  in 
the  observations  of  H.  Eeher  (Arch.  f.  cxpcr.  Path.  u.  PharmalvL,  xix. 
420,  1885),  of  E.  Neuhauss  (JBcrl.  Idin.  Wchnschr.,  xxiii.  389,  1886), 
and  of  A.  Chantemesse  and  F.  Widal  {Arch,  de  jjhysiol.  norm,  et  jMth., 
3  s.,  ix.  217,  1887)  was  not  conclusive.  In  Eberth's  case  the  bacillus 
was  found  in  the  blood,  the  spleen,  and  the  placenta;  the  foetus, 
hmvever,  was  born  dead,  as  it  was  also  in  Hildebrandt's  case  {Fortschr. 
d.  Med.,  vii.  889,  1889).  The  bacteriological  recognition  of  typhoid 
fever  in  the  living  foetus  was  carried  out  by  P.  Ernst  {Beitr.  z.  path. 
Anat.  u.  z.  allg.  Path.,  viii.  188,  1890) ;  in  the  instance  reported  by 
him  the  infant  lived  for  over  ninety-three  hours,  and  the  bacillus  was 
found  in  the  spleen,  the  brain,  and  the  marrow  of  the  femur;  the  mother, 
in  addition  to  her  typhoid  fever,  had  suffered  from  a  traumatism,  which 
it  was  thought  may  have  caused  haemorrhages  into  the  placenta  and 
facilitated  the  passage  of  the  micro-organism.  J.  Giglio's  observa- 
tion {C'entrlbl.  f.  Gi/ntlk.,  xiv.  819,  1890)  was  interesting  on  account 
of  the  early  period  in  antenatal  life  that  the  foetus  had  reached — three 
months.  V.  Frascani  {Biv.  (jen.  ital.  cli  din.  med.,  iv.  282,  348,  1892) 
made  careful  microscopic  examinations  of  three  foetuses  from  women 
suflering  from  typhoid ;  iu  one  of  these  it  is  interesting  to  take  note 
that  the  bacilli"  were  found  in  the  placenta  but  not  in  the  foetal 
organs.  Tlie  infant  with  congenital  typhoid  seen  Ijy  T.  Janiszewski 
{Miinchcn.  med.  Wchnschr.,  xL  705,  1893)  lived  for  fifteen  days.     In 


200  ANTENATAL    PATHOLOGY    AND    HYCilF.NF, 

these  cases,  as  also  in  that  ie]"tited  by  Freuiul  and  Levy  {ISerl.  l-l'ni. 
Wchnschr.,  xxxii.  539,  IS!),")),  there  was  no  special  localisation  of  ]iatho- 
logical  processes,  but  rather  a  general  blood  infection  with  tlie  typhoid 
bacilli.  Negative  bacteriological  results  were  obtained  by  G.  Uesinelli 
(Ann.  di  ostet.  e  gincc,  xviii.  G95,  1896),  all  the  cultures  from  the 
tVctus  of  a  mother  with  typhoid  remaining  sterile.  It  should  lie 
noted  that  souietrmes  there  seems  to  have  been  a  mixed  infection  as 
in  H.  Diirk's  observation  {Miinchcn.  inecl.  Wchrii^chr.,  xliii.  8-42,  1896), 
in  which  Eberth's  bacillus  of  typhoid  as  well  as  the  Striphi/loroccvs 
pyogenes  albiis  were  discovered  in  the  spleen  ;  further,  in  Fraenkel 
and  Kiderlen's  report  {Fortschr.  d.  Med.,  vii.  641,  1889)  the  typical 
bacilli  of  typhoid  were  not  found  at  all  but  only  the  y^tajihylococcvs 
pyogenes  albits  ct  Jfavus.  Mixed  infection  and  infection  with 
secondarily  developed  microbes  are  pathological  possibilities  which 
have  to  be  kept  in  mind  in  the  consideration  of  all  the  maladies 
that  may  be  transmitted  from  mother  to  tVctus. 

With  the  year  1896  came  the  discovery  of  the  Widal  serum  test 
for  typhoid  fever,  and  it  was  not  long  before  this  new  diagnostic 
means  was  applied  to  the  recognition  of  foetal  typhoid,  with  most 
interesting  developments.  G.  Etienne  (Pressc  mdd.,  p.  465,  1896) 
noted  the  aljsence  of  any  agglutinative  action  on  the  part  of  the  blood 
of  the  foetus  from  a  mother  who  had  died  from  a  severe  attack  of 
typhoid  fever ;  and  negative  residts  have  also  been  obtained  )jy  A. 
Dogliotti  {Gazs.  mcd.  di  Torino,  xlviii.  801,  821,  1897),  Charrier  and 
Apert  (Prcsse  mM.,  p.  cii.,  1896),  and  Plauchu  and  Gallavardin  {Lyon 
med.,  Ixxxviii.  479,  1898).  On  the  other  hand,  the  five  months  fa'tus 
which  I  saw  in  1897,  and  which  was  examined  and  fully  described  by 
W.  Fordyce  (Trans.  Edinh.  Obst.  Soc,  xxiii.  90,  1898),  gave  very 
marked  positive  results.  It  was  the  offspring  of  a  woman  who  died 
from  typhoid  fever  soon  after  delivery,  and  serum  taken  from  the 
jDeritoneal  cavity  of  the  foetus,  as  well  as  blood  from  the  heart,  showed 
very  distinctly  the  agglutinative  action ;  growths  of  the  typhoid 
bacillus  were  obtained  from  the  kidney,  spleen,  and  intestinal 
contents,  but  not  from  the  blood.  The  Widal  reaction  was  also  gi  it 
by  Chambrelent  (Journ.  d.  viM.  de  Bordeaux,  xxvii.  245,  257,  1897), 
J.  V.  Crozer  Griffith  (Med.  News,  Ixx.  626, 1897),  and  A.  Mosse  and 
Dannie  (Compt.  rend.  Soc.  de  bioL,  10  s.,  iv.  2:58,  1897).  In  Crozer 
Griffith's  case  the  infant  was,  save  for  slight  jaundice,  healthy  at  birth, 
and  continued  to  be  so  ;  nevertheless,  when  seven  weeks  old,  its  blood 
gave  the  Widal  reaction.  Griffith  thinks  that  the  child  may  have 
had  typhoid  fever  in  utero  and  recovered  after  a  very  short  attack,  or 
that  the  agglutinating  principle  may  have  passed  through  the  placenta 
from  mother  to  fretus  without  the  latter  contracting  the  disease  at 
all.  Ziingerle's  observation  svqiports  the  second  supposition  (Milnchen. 
mcd.  Wchnschr.,  xlvii.  890,  1900),  although  Crozer  Griffith  is  him- 
self inclined  to  favour  the  first.  The  whole  ([uestion  of  the  meUmd 
and  meaning  of  the  transmis.sion  of  the  agglutinating  jirinciple 
without  the  passage  of  the  disease  itself  must  still  be  regarded  as 
unsettled  (C.  Achard,  Compt.  rend.  Soc.  de  bioL,  10  s.,  iv.  255,  1897  : 
Mossc  and    Krenkel,   L'i'/l.   et  mini.  Soc.   nu'd.  d.  hop.  de  Par.,  3  s., 


FCETAL  TYPHOID  201 

xvi.  49,  1S99  ;  G.  Etienne,  Covqit.  void.  Soc.  dc  hioL,  11  s.,  i.  860, 
1899). 

Maternal  typhoid  fever,  in  addition  to  tlie  effects  that  have  been 
referretl  to  above,  may  liave  yet  anotlier  intiuence  upon  the  fcetns  in 
utero.  Xot  only  may  the  unborn  infant  talce  the  fever  and  show  the 
typical  manifestations  of  it,  not  only  may  the  pathogenic  bacteria  of 
typhoid  be  found  in  the  fretal  tissues  or  be  grown  in  cultures  from 
the  foetal  organs,  not  only  may  the  agglutinating  principle  be  trans- 
mitted through  the  placenta  and  be  discovered  in  the  serum  of  the  foetus, 
l>ut  there  may  be  also  met  with  certain  little  understood  but  vastly 
important  pathological  changes  in  the  fwtal  viscera,  more  particularly 
in  tlie  liver,  thyroid,  brain,  and  suprarenal  capsules,  which  have  a 
far-reaching  effect  upon  the  postnatal  life  of  the  offspring.  To  these 
changes  the  attention  of  the  profession  has  been  specially  directed  liy 
A.  Charrin  (C'onqif.  rend.  Soc.  de  hioL,  2  s.,  i.  550,  1899),  by  Charrrn 
and  Xattan-Larrier  (Journ.  dc  jjhysiol.  et  de  imth.  ghi.,  i.  292,  1899), 
and  by  Charrin,  Guillemonat,  antl  Levaditi  {Soe.  de  hioL,  January  6, 
1900);  they  consist  in  degenerative  and  sclerotic  alterations  un- 
accompanied by  the  presence  of  microbes,  but  productive  of  a  slacken- 
ing of  body  metabolism  and  lowering  of  body  temperature,  along 
with  a  tendency  to  develop  broncho-pneumonia,  gastro-enteritis,  and 
infantile  atrophy.  The  same  results  are  produced,  as  we  shall  see,  by 
other  infectious  maternal  conditions,  and  are  probably  due  to  the 
transmission  of  toxic  principles  through  the  placenta.  It  would  seem 
also,  from  some  oliservations  that  have  been  made,  that  these  trans- 
mitted toxines  may  produce  still  more  profound  alterations  in  ante- 
natal health,  taking  the  form  of  malformations  and  structural 
anomalies  ;  to  this  matter,  however,  I  shall  again  return.  Finally,  it 
has  been  thought  that  typhoid  fever  of  the  mother  iu  pregnancy  may 
lie  the  cause  of  intellectual  peculiarities  in  her  offspring,  developed 
many  years  afterwards  (J.  E.  Corbin,  Thesf,  Paris,  1890).  In  this 
connection,  the  case  reported  by  W.  Osier  {Teratolorjia,  ii.  13, 1895)  is 
peculiarly  suggestive  :  the  foetus  of  a  woman  who  died  from  typhoid 
fever  in  its  late  stage  was  removed  from  the  uterus  post-mortem :  in 
the  left  cerebral  hemisphere  there  was  a  large  recent  clot  wdiich  had 
broken  through  the  ganglia  into  the  lateral  ventricle  ;  the  mother  was 
also  the  subject  of  inherited  syphilis.  It  is  possible  that  the  foetal 
cerebral  hiemorrhage  was  due  to  the  maternal  typhoid ;  and,  had  the 
infant  lived,  it  would  undouljtedly  have  shown  phenomena  caused  by 
the  intracranial  condition. 

FcEtal  Malaria. 

Typhoid  fever  in  the  foetus  is  a  discovery  of  modern  medicine ; 
the  existence  of  foetal  malaria  was  known  to  Hippocrates.  There  is 
at  any  rate  an  obscure  reference  to  it  in  the  treatise  on  Airs,  Waters, 
and  Places,  in  which  it  is  stated  that  women  who  drink  unwholesome 
water  from  marshes  have  difficult  labours,  that  their  infants  are  large 
and  swelled,  and  that  during  nursing  they  become  wasted  and  sickly 
(83).     Several  reported  instances  are  to  be  found  in  medical  literature 


202  ANTENATAL    l'ATll()I.()(;V   AND    HVCIKNK 

prior  to  the  iiiuetoentli  century.  Thus  U.  F.  l';iulliiii  in  liis  ithscr- 
vationes  mcdico-physkcv  selectee  et  curiosce  (published  us  an  appendix  to 
the  .Mlsnllanra  curiosa,  Dec.  ii.,  Ann.  v.,  1(J87),  under  the  title  "  (^)uar- 
taua  infantis  in  utero,"  relates,  without  the  professional  secrecy  of  the 
present  day,  how  Anna  Dorothea  Meisenthurm,  a  soldier's  wife, 
sud'ered  from  a  tpiartau  a;,fue  in  whicli  her  fcctus  participated.  .  Here 
is  the  description  :  "  Ultiniis  luensilius  in  et  ante  paro.xysnnnu  eni- 
bryoueni  niaxinie  inquietuni,  treniuluni,  et  ab  uno  in  aliud  latns  sese 
volutantem  nianifeste  sensit,  ut  tristem  siljimetipsa  pnediceret 
eventuiu.  Tandem,  superato  eodem  die  terribili  paro.xysmo,  circa 
decimam  vespertinam  peperit  tiliolam,  ([ua?  una  eadeuKpie  hora,  una 
cum  matre,  febri  ista  misere  alHigebatur."  The  infant,  he  j^oes  on  to 
tell  us,  succumbed  in  about  .seven  weeks.  "  Mater  tandem,  Dei 
misericordia,  convaluit."  That  in  those  days  as  now  was  something 
to  be  thankful  for.  A  good  many  other  cases  of  a  similar  nature  are 
to  be  found  in  the  older  authors,  and  most  of  these  were  gathered 
together  by  Gr.'etzer  {Die  KrankhcHcn  dcs  Fotus,  p.  22, 1837).  One  of 
them  I  reproduce  here  in  full,  as  a  type  of  antenatal  pathology  and 
diagnosis  in  the  close  of  the  eighteenth  centm-y,  for  it  is  well  worth 
reproducing.  It  is  "  The  Account  of  a  Case  of  Ague  in  a  Child  in 
Utero,"  by  Dr.  1*.  Russel  (Trans.  Soc.  Improve.  Med.  and  Chir.  KnoivL, 
ii.  96,  1800).     Here  it  is  in  Dr.  Eussel's  own  words: — 

"  In  the  mouth  of  June,  17(J7,  a  young  healthy  woman,  at  Aleppo, 
already  the  mother  of  two  children,  and  then  in  the  seventh  month 
of  her  third  pregnancy,  was  attacked  with  a  tertian  fever.  The  fits 
returned  regularly  about  noon,  and  terminated  in  less  than  ten  hours 
by  a  profuse  sweat ;  Init  it  was  remarkable  in  this  case,  that  the  fo'tus 
seemed  to  suffer  a  paroxysm  perceptibly  distinct  from  that  of  the 
mother.  About  eight  in  the  morning  of  the  odd  days,  the  woman 
felt  the  child  (as  she  expressed  it)  tremble  with  great  violence  ;  and 
she  was  sensible  at  the  same  time  of  a  sudden  weight  and  coldness  in 
the  womb.  The  coldness  went  off'  in  less  than  fifteen  minutes,  and 
was  succeeded  for  more  than  an  hour  by  a  glowing  heat,  duririg  which 
the  child  was  at  intervals  somewhat  restless,  though  its  motions  then, 
she  .said,  were  not  tremulous,  but  like  what  she  had  felt  at  other  times 
when  in  health.  While  this  happened  to  the  child,  the  mother  to  all 
appearance  remained  well :  her  pulse  was  not  altered,  and  she  only 
complained  of  lassitude  and  a  dull  pain  in  the  forehead,  the  usual 
forerunners  of  the  paroxysm.  On  the  access  of  the  fever  at  noon  the 
child  again  became  unquiet.  It  stirred  but  little  while  the  cold  fit 
lasted,  and  throughout  the  hot  fit  was  alternately  quiet  and  restless. 
The  mother  constantly  insisted  that  the  struggles  of  the  child  at  noon 
were  totally  of  a  dillcrent  kind  from  the  tremulous  motion  of  which 
she  was  sensible  in  the  morning.  The  same  circumstances  invariably 
attended  every  fit  until  the  eleventh  day  of  the  disease.  The  pcruvian 
bark  was  administered  on  the  termination  of  the  fifth  paroxysm.  On 
the  eleventh  day,  tlie  child  remained  quiet  all  the  morning,  and  the 
mother,  feeling  less  of  her  usual  headache  and  lassitude,  was  in  hopes 
of  being  cured  as  well  as  the  child.  Her  tit,  however,  returned  at 
noon  as  violent  as  ever,  and  the  child,  who  till  that  time  had  lieen 


FQa'AL   MALARIA  203 

perfectly  ijiiiet,  became  disturbed  as  usual  during  the  mother's 
paroxysm.  The  bark  was  repeated  in  the  succeeding  intermission, 
and  the  fever  did  not  return.  I  have  met  with  a  few  instances  some- 
what similar,"  adds  Dr.  Ilussel,  "  but  in  all  of  them  more  might  be 
ascribed  to  the  power  of  the  mother's  imagination  than  in  the  present 
case,  the  patient  being  a  woman  of  remarkable  good  sense,  of  a 
chearful  (m-)  disposition,  and  who  had  never  been  subject  to  hysteric 
ailments." 

Unfortunately,  the  author  does  not  record  the  state  of  the  infant 
at  bii'th,  but  even  in  the  absence  of  information  on  this  point  the  case 
is  both  curious  and  interesting.  If  we  accept  the  conclusion  that  the 
fcetus  sutiered  from  malaria  in  uterci,  then  it  would  appear  that  its 
seizures  did  not  occur  simultaneously  with  those  of  the  mother.  The 
occurrence  of  foetal  malaria  of  a  different  type  from  that  of  the  mother 
has,  however,  been  noted  by  other  writers.  Further,  the  diagnosis  of 
the  fcetal  malady  is  an  interesting  feature  of  the  case,  and  a  still  more 
interesting  one  is  the  success  of  antenatal  treatment,  a  success  gained 
apparently  more  quickly  for  the  fcetus  than  for  the  mother. 

Xotwithstanding  the  publication  of  Eussel's  case,  and  others  of  a 
somewhat  similar  kind,  Leroux  found  it  necessary  in  1882  (Eev.  dc 
mcd.,  ii.  561,  1882)  to  collect  together  all  the  available  evidence  in 
order  to  establish  the  probability  even  of  the  occurrence  of  fcetal 
malaria.  He  put  on  one  side  the  evidence  founded  solely  upon  the 
history  of  intrauterine  shivering  fits  noted  by  the  mother  as  un- 
reliable, and  gave  more  weight  to  the  discovery  of  hypertrophy  of 
the  spleen  discovered  at  birth.  The  cases  of  G-.  E.  Playfair  {MM. 
Med.  Journ.,  ii.  901,  1856-7),  of  Bouchut  (Gaz.  d.  hop.,  xxxi.  221, 
1858  ;  XXXV.  245,  1862),  of  Brunzlow  {Mcd.  Ztg.,  x.  57,  1841),  of 
Schupmann  {Journ.  f.  Gchurtsh.,  xvii.  318, 1838),  of  P.  Aubinais  {Journ. 
dc  la  Sect,  de  med.  Sac.  acad.  Loire-inf.,  xxvi.  15,  1850),  of  Lepidi 
{Morgar/ni,  xii.  923,  1870),  of  Bohu  {JaJirb.  d.  Kindcrh.,  n.  F.,  vi.  115, 
1873),  of  Bazin  {Gaz.  d.  hop.,  xliv.  286,  1871),  and  of  Bureau  {Rev. 
mens,  de  mi'd.  el  chir.,  iv.  214,  1880)  have  all  some  value ;  but  in  the 
end  Leroux  comes  to  the  conclusion  that  "  les  observations  ne  sout  ni 
assez  nombreuses  ni  assez  probantes."  His  sceptical  position  would 
seem  to  be  largely  due  to  the  discovery,  made  about  the  time  his 
communication  was  published,  of  the  ha-matozoon  malarife  of  Laveran, 
and  to  the  belief  then  current  that  formed  bodies,  such  as  h;ematozoa, 
could  not  pass  the  placental  barrier. 

Since  the  time  of  the  recognition  of  the  causal  haematozoon  or 
Plasmodium  of  malaria,  the  number  of  reported  cases  of  foetal  malaria 
has  increased,  as  is  shown  by  tlie  publication  of  observations  by 
Yerneuil  {Bcr.  de  med.,  ii.  641,  1882),  by  W.  T.  Taylor  {Amcr.  Journ. 
out.,  xvii.  538,  1884),  bv  F.  Cima  {Pcdiatria,  i.  231,  1893),  by  F.  M. 
Crandall  {N.  Yorh  Polyclin.,  i.  38,  1893),  by  Moncorvo  {Med.  inf.,  ii. 
363,  1895),  and  by  K.  Winslow  {Boston  Mcd.  and  Surg.  Journ.,  cxxxvi. 
514,  1897).  Felkin's  two  cases  {Trans.  Edinh.  Gist.  Soc,  xiv.  71, 
1889)  are  chiefly  noteworthy  for  the  reason  that  in  both  instances 
the  mothers  were  free  from  malaria,  and  that  apparently  tlie  disease 
had  been  transmitted  from  the  fathers  to  the  foetuses  without  the 


204  ANTENATAL    I'ATHOIXXiY   AND    HYGIENE 

mothers  being  uH'ected.  ^Vtteiuiits  lo  discover  the  ha-niiitozoou  in  the 
fcetal  tissues  have  not  been  crowned  with  success,  for  V.  Cacciui 
{Bull.  d.  Soc.  Lancisiana  d.  osp.  di  Homa,  xvi.  12,  1895-6)  and 
Bastianelli  {ibid.,  xii.  48,  1892)  botii  obtained  negative  results.  This 
failure,  liowever,  cannot  be  used  as  conclusive  evidence  against  the 
possibility  of  transmission  of  malaria  from  mother  to  fcntus,  for  in 
typhoid  as  we  have  seen,  and  in  tubercle  as  we  shall  see,  it  is  exce])- 
tional  to  find  the  causative  organism  in  the  fuHal  tissues.  It  may 
also  be  urged  that  the  peculiarities  of  malarial  infection  and  tlic 
necessity  of  the  presence  of  the  mosquito,  Anophcloi,  may  prevent  or 
make  very  difficult  the  intrauterine  transmission  of  the  disease ;  but 
it  must  be  remembered  that  the  passage  of  malaria  from  mother  to 
foetus  is  not  to  be  compared  to  the  infection  of  one  individual  by 
another;  there  may  be  no  need  for  the  intermediate  devclojiniental 
phases  of  the  malaria  parasite  when  the  fcetus  is  to  lie  tlie  host,  the 
mother  and  foetus  being  co-hosts  as  it  were.  At  any  rate,  there  is 
good  reason  to  believe  that  tlie  parasite  {H(emam<xha,  Hccmatozoon) 
can  pass  the  placental  barrier,  more  especially  if ,  as  Varaldo  {loc.  cit.) 
maintains,  white  blood  corpuscles  habitually  do  so.  There  may  be 
some  doubt  whether  the  red  corpuscles  of  the  foetal  Ijlood  may  be  so 
easily  invaded  by  the  parasite  as  are  those  of  adult  blood.  The 
question  must  l)e  left  unsettled. 

To  summarise :  It  would  appear  that  the  foetus  may  lie  attected 
with  malaria  in  utero  and  be  born  with  the  hypertrophied  sjileen  of 
that  malady ;  it  may  receive  from  the  maternal  organism  toxic- 
products  which  interfere  with  its  nutrition  and  cause  it  to  be  bom 
delicate  and  little  able  to  resist  postnatal  infections ;  and  it  may 
possiblj'  sometimes  be  expelled  from  the  uterus  with  a  partial  im- 
munity against  malaria  (P.  Pennato,  Eiforina  mcd.,  xiii.  1,  4,  206, 
1897).  Tiie  fear  of  inducing  abortion  or  premature  labour  by 
administering  quinine  to  a  pregnant  woman  who  is  suH'ering  from 
ague  seems  to  l)e  largely  imaginary;  to  give  that  drug  would  rather 
appear  to  be  good  treatment  both  for  mother  and  foetus. 

The  types  of  transmitted  foetal  disease  which  have  Ijeen  chosen 
for  description  in  the  present  chapter  offer  some  interesting  contrasts 
as  well  as  some  evident  resemblances.  Their  consideration  leads  us 
to  the  inevitable  conclusion  that  the  manifestations  and  mechanism 
of  intrauterine  transmission  are  much  more  complicated  than  miglit 
at  first  thought  have  been  anticipated.  It  is  evident  that  a  disease 
such  as  measles  or  smallpox  may  pass  from  mother  to  f<ptus,  and 
show  itself  in  the  latter  in  the  same  form,  or  in  nearl)-  the  same  form, 
as  in  the  former.  It  is  evident  also,  from  what  is  known  of  foetal 
typhoid  and  erysipelas,  that  in  the  unborn  infant  the  disease  may 
take  on  characters  which  are  unknown  or  at  least  seldom  met  witli  in 
the  adult ;  these  characters  are  in  great  measure  due  to  the  route  by 
whicli  the  infection  reaches  the  ftctus,  and  to  the  ]ieculiarities  of 
fd'tal  physiology.  Further,  it  is  clear  that  the  fiotus  in  utero  may 
suffer  not  only  from  the  attacks  of  the  causative  micro-organism  of 
the  maternal  disease,  hut  also  from  those  of  secondary  infections 
(streptococcic  or  staphylococcic):  in  some  instances  the  effect  of  tlie 


I 


TRANSMISSION    OF   DISEASES    IN    UTERO  205 

latter  may  be  more  prejudicial  than  that  of  the  former.  Apparently 
the  fd'tus  is  sometimes  immunised  in  utero  by  a  process  other  than  liy 
suflering  from  the  disease  itself.  This  is  a  complicated  and  involved 
c[uestion,  but  may  possibly  be  explained  by  the  action  of  the  placental 
tissixes  upon  the  toxiues  or  antitoxines.  There  is  some  evidence 
that  a  disease  may  pass  from  the  paternal  to  the  foetal  organism  vid 
the  maternal  body  without  the  last-named  showing  signs  of  infection. 
These  are  some  of  the  considerations  suggested  by  the  foetal  maladies 
above  reviewed.  They  throw  light  upon  some  problems  of  intra- 
uterine transmission,  but  they  appai-ently  darken  others — apparently 
only,  for  it  cannot  be  doubted  that  in  time  and  with  further  know- 
ledge will  come  elucidation.  There  I'emains  misolved  the  large 
problem  stated  thus  by  Mademoiselle  Margoulieff,  "  Par  quel  caprice 
pathologique  le  placenta  laisse-t-il  passer  le  meme  micro-organisme 
qu'il  arretera  dans  un  autre  cas  ?  "  (These,  Paris,  1889).  At  present 
we  can  only  repeat,  "  par  quel  caprice  ? "  hut  we  Icnoio  that  it  is  no 
caprice. 


CHAPTER    XllJ 

Types  of  Tiansinitted  Fictal  Diseases;  Fietal  Tubercle;  Evidence  of  its  Exist- 
ence ;  Causes  of  its  Karity  ;  C-'liaraotcrs  ;  Baunigarteu's  Theory  of  Latency  : 
Non-tubercular  Manifestations  of  Antenatal  Tuljercle  ;  Projiliylaxis  ;  Firtal 
Sejisis  ;  Fcetal  Epidemic  Cerebro-spinal  Meningitis  ;  Futal  Purpura  ;  Fietal 
Pneumonia  ;  Fatal  Anthrax  ;  Fo'tal  Rheumalii-  Fever. 

FtETAL  TunERCULOSis,  which  is  the  subject  to  the  consideratiuu  of 
which  I  shall  devote  the  greater  part  of  this  chapter,  is  a  inorlm! 
entity  whose  existence  has  been  insisted  upon  by  one  school  of 
pathologists  and  as  stoutly  denied  by  another.  It  has  given  rise  tn 
numberless  discussions,  which  have  served  this  useful  purpose,  if  nu 
other : — they  have  for  a  while  focussed  the  minds  of  pathologists  and 
physicians  upon  the  vexed  question  of  intrauterine  and  iiitrao\'ular 
transmission  of  disease,  of  the  paternal  influence  in  heredity,  and  of 
the  dilierenee  between  hereditary  predisposition  to  tubercle  and  foRtal 
infection  with  tuliercle.  Tliese  are  questions  which  the  profession 
cannot  afford  to  pass  by.  At  this  time,  when  a  campaign  is  going  on 
against  tuberculosis,  it  is  manifestly  a  matter  of  no  little  importance 
to  consider  well  all  the  aspects  of  the  subject.  It  would  be  bad 
generalship  in  such  a  campaign  not  to  reconnoitre  every  part  of  the 
enemy's  position ;  were  precautions  of  this  kind  neglected,  masked 
Imtteries  might  open  fire  at  a  critical  stage  in  the  great  battle,  and 
lead  to  irretrievable  disaster.  It  is  therefore  incumbent  upon  us,  in 
our  struggle  against  tubercidosis,  to  make  a  reconnaissance  in  force 
with  a  view  to  discover  what  may  be  the  strength  of  the  antenatal 
section  of  the  hostile  attacking  forces.  In  other  words,  it  is  neces- 
sary to  take  into  account  antenatal  as  well  as  postnatal  tuberculosis. 
Tubercle,  "  cette  maladie  de  tons  les  peuples,  de  tons  Ics  milieux,  on 
poiuTait  presque  dire  de  toutes  les  families,"  is,  in  a  certain  sense  and 
to  a  certain  extent,  a  preventable  disea.se  ;  for  it  may  be  possible 
greatly  to  diminish  the  risks  of  the  entrance  of  tubercle  bacilli  into 
the  human  body,  even  if  it  can  scarcely  be  hoped  that  the  chances  of 
such  a  microbic  invasion  will  be  altogether  abolished.  If  it  were 
found  possible  to  exterminate  absolutely  the  immediate  cause 
(microbic  or  toxinic)  of  tubercle,  it  might  then  be  permissible, 
perhai)s,  to  neglect  the  question  of  the  receptivity  or  unreceptivity  of 
the  body-cells  with  regard  to  that  microbic  or  toxinic  cause.  If 
there  were  no  seed  being  sown,  it  would  not  matter  much  about  the 
soil ;  but  there  is  seed  in  abundance,  and  heuce  it  does  matter 
about  the  soil.     Therefore,  in  any  attempt  to  prevent  tubercle,  the 


F(ETAL  TUI5RRCLK  207 

problem  resolves  itself  into  the  prevention  of  the  incidence  of  tnbercle 
bacilli  upon  the  tissues  of  the  body,  and  (since  this  cannot  be  carried 
out  with  absolute  success)  into  the  preparation  of  the  tissues  to 
resist  the  morbid  action  of  the  bacillary  invaders.  Now,  this  is  not 
a  problem  of  postnatal  life  only :  it  is  also  a  proljleni  of  antenatal 
life,  for  the  organism  before  birth  is  liable  to  the  attacks  of  tubercle 
bacilli  and  toxines,  and  its  tissues  may  likewise  be  more  or  less  able 
to  repel  such  attacks.  Further,  the  antenatal  side  of  the  problem 
has  an  important  bearing  upon  the  postnatal.  For  this  reason,  there- 
fore, if  for  no  other,  the  suliject  is  well  worthy  of  study. 

In  the  present  chapter  I  am  concerned  with  fo'tal  tuberculosis, 
l)ut  it  must  not  lie  forgotten  that  possilily  the  organism  may  fall 
under  the  influence  of  the  tubercular  poison  during  one  or  other  of 
the  two  earlier  epochs  of  antenatal  life.  It  may  be  infecte.d  during 
the  embryonic  or  during  the  germinal  period  as  well  as  during  the 
fcetal.  Of  the  possibility  of  the  ovum  being  invaded  by  a  tubercle 
bacillus  when  in  the  ovary,  or  when  passing  down  the  Fallopian  tube, 
and  of  the  possibility  of  it  Ijeing  penetrated  by  a  spermatozoon  whicli 
has  a  bacillus  in  its  interior,  I  shall  have  something  to  say  iinder  the 
head  of  Germinal  Pathology.  The  effect  of  the  tubercular  poison 
upon  the  organism  in  the  embryonic  or  developmental  period  of  its 
antenatal  existence  will,  as  I  shall  afterwards  show,  probably  take 
the  form  of  interference  with  development,  i.e.  of  malformation.  In 
the  meantime,  however,  let  us  focus  our  attention  upon  foetal  tuber- 
culosis, upon  the  cases  in  which  there  is  reason  to  believe  that  the 
niorliid  processes  in  the  foetus  are  set  up  between  the  second  and  the 
ninth  months  of  intrauterine  life. 

Evidence  of  the  Existence  of  Foetal  Tuberculosis. 

The  evidence  which  may  Ije  and  has  been  adduced  in  support  of  a 
lielief  in  the  existence  of  foetal  tuberculosis  may  lie  direct  or  indirect. 
The  direct  evidence  is  founded  upon  the  discovery  of  tubercular 
lesions  in  the  foetus,  upon  the  recognition  of  the  tubercle  bacillus  in 
its  tissues,  and  upon  the  fact  that  its  lilood  and  organs  when  injected 
into  animals  lead  to  the  development  of  tuljercular  processes.  The 
indirect  evidence,  of  much  less  value,  rests  upon  the  discovery  of  signs 
of  tubercle  in  the  placenta,  umljilical  cord,  and  liquor  amnii,  and  upon 
the  tulierculinisation  of  the  new-born  infant  of  a  tubercular  mother. 

I  shall  here  descrilje  three  typical  cases  of  foetal  tuberculosis :  the 
first  of  them  occurred  before  the  discovery  of  the  tubercle  bacillus, 
and  its  diagnosis  rests,  therefore,  upon  the  lesions  present  in  the 
fcEtus ;  the  second  is  a  fully  estalilished  case  according  to  the  exacting 
requirements  of  the  modern  definition  of  tuberculosis ;  and  the  third 
is  an  instance  of  tubercle  without  evident  lesions,  in  which  the  proof 
depended  upon  experimental  inoculations. 

The  first  case  of  foetal  tuberculosis  which  I  select  as  a  type  is  that 
reported  in  1873  by  Charrin  {Mem.  et  Compt.  rend.  Sue.  de  sc.  mkl.  de 
Lyon  (for  1873),  xiii.,  pt.  2,  65,  1874).  There  were  cases  put  on 
record  before  this  date,  but  most  of  them  were  incompletely  stated 


208  ANTENATAL    I'ATHOLOCV    AND    HYGIENE 

mill  unconvincing;  ChaiTin's  case  was  fairly  complete  in  its  clinical 
and  pathological  details,  and  as  convincing  as  it  could  be  in  the 
absence  of  modern  bacteriological  tests.  The  mother  was  a  tripara, 
29  years  of  age,  who,  at  the  fourth  month  of  her  pregnancy,  developed 
a  pleurisy ;  at  the  seventh  she  had  all  the  signs  and  symptoms  of 
phthisis.  At  this  time  labour  came  on  prematurely,  and  she  died  ten 
ilays  later;  at  the  autopsy,  tubercles  were  found  in  the  lungs  and 
pleura  and  in  the  spleen  and  kidneys,  the  bronchial  glands  were 
caseous,  and  the  liver  was  much  enlarged  and  fatty.  The  genital 
organs  were  normal.  The  placenta,  unfortunately,  was  not  availalilc 
for  examination.  The  foetus,  a  female,  weighed  only  1100  grms.  at 
birth,  and  had  a  greatly  distended  abdomen ;  it  was  very  feeble,  and 
died  in  three  days,  after  having  developed  a  general  cedema.  At  the 
necropsy,  miliary  tubercles  were  found  in  the  kidneys,  suprarenal 
capsules,  great  omentum,  spleen,  and  liver;  the  abdominal  cavity 
contained  much  clear  yellow  serum  with  tiakes  of  lymph  in  it ;  the 
mesenteric  glands  were  much  enlarged,  and  were  nearly  all  caseous  ; 
the  bronchial  glands,  also,  were  caseous;  and  there  were  some  scat- 
tered grey  granulations  in  the  lungs.  Charrin  draws  attention  to  the 
localisation  of  the  lesions  in  the  fcetus  as  compared  with  the  mother, 
abdominal  in  the  former,  thoracic  in  the  latter;  and  he  rightly 
emphasises  the  apparent  rapidity  of  transmission  of  the  tubercular 
process  from  mother  to  fa3tus.  Several  of  the  circumstances  wliich 
struck  the  author  as  peculiar  and  difficult  to  explain  are  now  well 
known  and  easily  understood  by  all  who  have  studied  Antenatal 
Pathology :  there  is  nothing  in  this  recorded  case  to  make  us  doulit  thai 
it  was  really  tubei'cle  of  the  foetus  ;  no  doubt  it  was  a  very  rare  instance 
of  it  (for  it  will  be  shown  that  it  is  extremely  rare  to  meet  with  such 
marked  and  widespread  lesions),  but  yet  indubitably  fietal  tubercle. 

The  recently  observed  case  of  Auche  and  Chambrelent  (Arch,  di' 
mM.  exper.  d  d'anaf.  path.,  xi.  521,  1899)  will  serve  excellently  as  a 
type  of  a  fully  established  instance  of  fcetal  tuberculosis.  It  was  that  of 
a  prematurely  Ijorn  but  living  female  infant,  the  product  of  the  fourth 
pregnancy  of  a  tubercular  woman,  forty  years  of  age,  who  died  three 
days  after  her  confiuement.  It  was  found  at  the  autopsy  that  she 
(the  mother)  had  been  the  subject,  not  only  of  far  advanced  pul- 
monary phthisis,  but  also  of  tubercular  disease  of  the  liver,  spleen, 
intestines,  mesenteric  glands,  and  kidneys.  The  ovaries,  Fallojiian 
tubes,  and  uterus  were  healthy,  and  there  were  no  signs  of  peritonitis. 
The  other  children  of  this  woman  were  alive  and  well,  but  in  her 
family  history  there  was  the  record  of  the  death  of  one  sister  from 
phthisis.  There  was  no  history  of  alcoholism.  The  infant,  which  was 
born  between  the  sixth  and  seventh  months  of  intrauterine  life,  sur- 
vived in  the  couveuse  for  twenty-six  days,  and  then  died  without 
having  exhibited  any  marked  symptoms.  It  had,  however,  lost 
weight  continuously.  At  the  autopsy  no  peritonitis  was  found,  and 
the  intestinal  canal  showed  no  tubercular  lesions.  In  the  liver,  how- 
ever', were  numerous  yellow  granulatitms ;  in  the  spleen  there  were 
crowds  of  the  same  coniluent,  punctiform  granulations  ;  while  in  the 
lungs  were  grey,  transparent,  round  granulations   in   much  smaller 


FCETAL  TUBERCLE  209 

numbers.  The  bronchial  glands  were  tubercular,  but  the  other 
organs  had  a  normal  appearance  as  seen  by  the  naked  eye.  Micro- 
scopic examination  revealed  an  excessive  number  of  tubercles  in  the 
liver,  some  caseated  in  the  centre,  along  with  an  enormous  quantity 
of  Koch's  bacilli.  The  same  condition  was  found  in  the  spleen. 
Tliere  were  no  giant  cells.  Many  bacilli  were  fovmd  in  the  pul- 
monary alveoli.  Further,  tubercular  endocarditis  in  the  right 
ventricle  was  discovered  by  means  of  the  microscope.  It  remains  to 
be  noted  that  the  placenta  showed  many  tubercular  granulations, 
some  caseous  at  the  centre  and  others  not ;  the  chorionic  villi  were 
in  some  places  little  altered,  in  others  they  were  lost  in  the  caseous 
portions ;  some  giant  cells  were  seen,  and  bacilli  were  present, 
although  they  were  not  so  enormously  numerous  as  in  the  fojtal 
organs.  Three  rabbits  were  inoculated  with  fragments  of  the  liver, 
spleen,  and  lung  from  the  infant,  and  these  all  died  of  generalised 
tubercle,  with  numerous  bacilli  in  the  lesions.  A  piece  of  placenta 
was  inserted  under  the  skin  of  a  guinea-pig ;  two  months  later  the 
animal  was  examined,  when  it  was  found  that  tubercular  infection 
had  occurred.  Finally,  two  cubic  centimetres  of  blood  from  the 
imibilical  cord  were  injected  into  the  peritoneal  cavity  of  another 
guinea-pig  without  any  apparent  results ;  but  the  animal  died  nearly 
a  year  later,  when  it  was  discovered  that  there  was  tubercle  of  the 
peritoneum,  mesenteric  glands,  liver,  spleen,  and  lungs,  with  bacilli 
in  all  the  lesions. 

Some  five  or  six  further  cases,  in  which  the  evidence  in  favour 

of  the  existence  of  foetal  tuberculosis  was  as  clearly  or  nearly  as 

clearly  estabhshed,  have  been  reported  during  the  past  ten  or  twelve 

years;  but  it  is  freely  confessed  by  all  who  have  investigated  the 

subject,  that  such  instances  are  extremely  rare.     It  would  seem,  also, 

from  G.  Kiiss's  masterly  exposition  of  the  whole  question  of  antenatal 

tuberculosis  {De  I'hMdiU  ixcrasitairc  de  la  tuherculose  humaine,  Paris, 

1898),  that  well-established  cases  in   the  fcetal  calf  are  almost  as 

uncommon  as  in  the  human  subject.     The  reasons  which  have  been 

advanced  to  explain  this  great  rarity  will  be  referred  to  later;  in 

the  meantime,  the  fact  that  at  birth  evident  tubercular  lesions  are 

I   most   exceptional  in  the   offspring  of  tubercular  mothers,  must  be 

I  accepted  as  fully   proven.      In   order,   however,  that   the   case   for 

j  congenital  tuberculosis  may  be  quite   fairly  stated,  some  reference 

I  must  be  made  to   the  third  type  of   the  malady,  that   in   which, 

I  although   evident   tubercular   lesions   were  not   met  with,  yet  the 

i   bacilli  were  found  in  the  fcetal  tissues,  and  inoculation  of  animals 

I  with  pieces  of  organs  or  blood  from  the  fetus  led  to  the  development 

I  of  tubercle.     About  twelve  instances  of  tuberculosis  without  lesions 

I  have  been  put  on  record,  including  those   of   Schmorl  and   Birch- 

\  Hirschfeld  (Beitr.  z.  path.  Anat.  u.  z.  allg.  Path.,  ix.  428,  1890),  of 

i  Aviragnet  {These,  Paris,  1892),  of  Londe  and  Thiercelin  {Gaz.  d.  hd})., 

I  Ixvi.  189,  1893),  of  Schmorl  and  Kockel  {Bcitr.  z.  jMth.  Anat.  n.  z. 

j  allff.  Path.,  xvi.  312,  1894),  of  Bar  and  Eenon  {Compt.  mid.  Soc.  dc 

I  hioL,  10  s.,  ii.  505,  1895),  and  of  Jens  Bugge  (Bcitr.  s.  jtath.  Anat. 

I  u.  z.  allg.  Path.,  xix.  433,  1896).     The  case  described  by  Bugge  may 

14 


210  ANTENATAL   PATHOLOCJY   AND   HYGIRNK 

1)6  given  as  a  good  exiunple  of  this  tyjie  of  antenatal  tuberculosis. 
It  was  that  of  a  woman,  ?>9  years  of  age,  the  daughter  of  a  plitliisical 
mother,  who  had  had  thirteen  children,  of  whom  ten  liad  died  of 
tubercle  and  one  was  ill  with  the  disease.  Two  years  previous  to 
the  birth  of  her  fifteenth  infant,  she  began  to  show  signs  of  i)hthisis, 
and  she  died  four  days  after  being  delivered  of  a  female  infant.  The 
necropsy  discovered  tubercular  changes  in  tlie  lungs,  liver,  lironcliial 
glands,  kidneys,  and  intestinal  canal.  The  placenta  was  not  ex- 
amined. The  infant  lived  for  thirty  hours  ;  it  was  prematurely 
born  (second  half  of  the  eighth  month),  and  weighed  1820  grms. 
With  the  naked  eye  no  tubercular  lesions  were  discoverable  in  the 
organs  of  the  infant ;  liut  microscopically,  bacilli  were  found  in  the 
blood  of  the  umbilical  vein,  aud,  to  the  number  of  four,  in  the  lumeu 
of  one  of  the  small  vessels  of  the  liver.  Further,  blood  from  the 
umbilical  vein,  and  a  piece  of  the  liver,  were  inoculated  into  three 
guinea-pigs,  all  of  which  succumbed  from  tubercle  in  two  and  a  hall', 
four  and  a  half,  and  five  and  a  half  mouths  respectively.  In  this 
case  it  is  larobable  that  foetal  infection  occurred  late  in  pregnam  y, 
possibly  even  in  the  course  of  laljour. 

Of  indirect  evidence  bearing  upon  the  occurrence  of  fcetal  tuber- 
culosis it  is  unnecessary  to  saj-  much.  The  histological  and  bacterin- 
logical  examination  of  the  placenta  and  membranes  in  all  cases,  but 
especially  in  those  in  which  the  infant  survives  birtli,  ought  to  1  ii' 
carried  out;  but  the  discovery  of  tubercular  lesions  or  bacilli  in  Uie 
foetal  annexa  does  not  of  necessity  indicate  tuberculosis  of  the  fo'tus 
itself,  as  was  shown  some  years  ago  by  Schmorl  and  Kockel  {Beitr. 
z.path.  Anat.  v..  z.  allcj.  Path.,  xvi.  312,  1894).  With  regard  to  the 
examination  of  the  blood  of  the  umbilical  cord,  and  the  inoculation 
of  animals  with  it,  Kiiss  {op.  cit.)  has  pointed  out  that,  while  positi\  e 
results  may  have  a  certain  value,  negative  ones  have  very  little,  fur 
the  bacilli  of  tubei-cle  are  rarely  found  in  the  blood.  InoculatiDus 
of  animals  with  liquor  amnii  from  cases  in  which  the  mother  was 
tubercular  have  been  little  practised ;  Herrgott  {Ann.  dc  ijyna-.  d 
d'ohsf.,  xxxvi.  1,  100,  1891)  obtained  positive  results  in  one  case; 
but  tubercle  bacilli  in  the  liquor  amnii  do  not  necessaril}'  mean 
tubercle  of  the  fcetus.  A  more  useful  means  of  investigation  may 
be  found  to  be  the  testing  of  new-born  infants,  the  offspring  ni 
tubercular  mothers,  with  tuberculin ;  but  in  the  meantime  it  is 
doubtful  whether  the  medical  man  would  be  justified  in  using  this 
method,  even  if  the  parents  were  ready  to  give  their  consent.  After 
all,  it  is  unnecessary  to  have  recoiu'se  to  indirect  evidence  to  prnve 
the  occasional  but  rare  occurrence  of  foetal  tuberculosis ;  that  fad 
is  sufficiently  proved  by  the  direct  evidence.  Foetal  tubercle  occurs, 
Ijut  it  occurs  with  almost  extraordinary  rarity.  Let  us  inquire  . 
whether  there  is  any  explanation  of  this  great  rarity. 

Causes  of  Rarity  of  Fcetal  Tuberculosis. 

It  must,  in   the   first  place,  be   borne  in   mind  that    tlie   irans- 
jilacental  passage  of  diseases,  and  even  of  the  most  transmissible 


Fa:TAL  TUBERCLE  211 

diseases,  is  far  from  constant.  Already,  in  describing  fictal  smallpox, 
measles,  scarlet  fever,  etc.,  I  have  pointed  ont  the  rarity  of  tliese 
maladies.  Not  every  woman  wlio  sutlers  from  one  or  other  of  the 
infectious  fevers  transmits  the  same  to  her  unborn  infant ;  she  may 
transmit  some  morbid  influence  which  may  show  itself  in  weakened 
foetal  metabolism  of  one  kind  or  another,  but  it  is  exceptional  for 
her  to  pass  on  the  disease  itself.  The  reasons  for  this  rarity  of 
transmission  have  been  considered  under  the  head  of  the  Placental 
Factor  in  Fwtal  Pathology,  and  need  not  be  reconsidered ;  suffice  it 
that  the  placenta  sometimes  acts  as  a  prophylactic  barrier.  In  the 
case  of  tubercle,  however,  there  are  also  special  reasons  why  the 
foetus  is  so  rarely  afiected.  In  order  that  the  tubercle  bacilli  may 
reach  the  foetus  in  utero,  they  must  be  present  in  the  blood  of  the 
mother  and  pass  through  the  placenta,  for  there  is  practically  no 
other  avenue  of  entrance.  The  ordinary  mode  of  infection  (viz. 
pulmonary  and  aerial)  is  out  of  the  question  for  the  fcetus.  Now, 
it  is  an  unconnnon  occurrence  for  the  Ijacilli  of  tubercle  to  be  present 
in  the  blood-stream ;  they  can  live  in  it,  and  do  so  in  advanced  cases 
of  general  tuberculosis,  but  they  constantly  show  a  tendency  to 
escape  from  it  and  to  become  localised  in  special  organs.  In  a 
sentence,  an  intense  blood-infection  is  quite  rare  in  tubercle.  It  is 
not  often  that  women  showing  marked  and  generalised  tuberculosis, 
with  numerous  bacilli  in  the  blood-stream,  come  to  the  full  term,  or 
even  to  the  seventh  month,  of  pregnancy ;  therefore  it  is  rare  for 
tubercle  bacilli  to  arrive  in  the  placenta.  Even  in  ordinary  phthisis, 
howe\'er,  it  is  possible  that  bacilli  reach  the  placenta ;  Ijut  then  there 
is  some  evidence  that  the  placenta  is  not  a  good  culture  medium  for 
them,  and  even  if  that  be  not  so,  there  is  the  natural  tendency  of 
the  organ  to  act  as  a  barrier  to  microbic  invasion.  So  that  it  is  easy 
enough  to  believe  that  few  germs  actually  arrive  in  the  fcetal  tissues. 
Further,  it  may  be  hazarded  that  the  twtal  liver  may  act  as  a  second 
barrier  in  the  way  of  a  successful  Ijacillary  invasion ;  and  that,  being 
the  potent  organ  in  fietal  life,  which  it  undoubtedly  is,  it  may  act  in 
concert  with  or  as  a  substitute  for  the  placenta,  and  thus  save  many 
a  fcetus  from  tubercular  contamination.  Some  additional  causes  of 
the  rarity  of  ftetal  tubercle  may  be  referred  to  briefly.  There  is  the 
rarity  of  primary  tubercular  lesions  of  the  genital  organs  (uterus, 
ovaries,  and  Fallopian  tubes)  of  the  mother.  J.  D.  Williams  and  I 
met  with  and  reported  a  case  of  primary  tulierculosis  of  the 
Fallopian  tubes  .some  years  ago  (19),  but  such  cases,  as  also 
examples  of  primary  tubercle  of  the  ovaries  (Loeffler,  Wien.  med. 
1  Wchnschr.,  August  26,  1899),  are  exceedingly  rincommon.  No  doubt, 
I  if  tubercular  changes  in  the  tubes,  ovaries,  and  mucous  membrane  of 
the  litems  were  more  often  met  with,  placental  tubercle  would  be 
;  more  common,  and  cases  of  fcetal  infection  would  he  less  rare  than 
I  they  are.  Finally,  it  is  possible  that  if  fwtal  tubercle  were  more 
j  often  and  more  carefully  looked  for  in  the  still-born  foetuses  of 
I  tubercular  women,  it  would  be  more  often  found.  At  any  rate, 
[  enough  evidence  has  been  led  to  demonstrate  the  causation  of  its 
■  apparent  rarity. 


212  ANTKNA'I'AI,    I'AI'IIOLOCY    AND    IIYCHEN'K 


Characters   of  FcEtal   Tubercle. 

Fcetal  tuberele  differs  from  iufiiiitilc  iiiiil  ndiilt  ttilierele  in  its 
characters;  but  the  difl'erences  are  .such  as  can  he  cxjilained  hy  the 
geueral  laws  of  antenatal  as  distinguished  from  ])()stnatal  pathology. 
In  otlier  words,  f fetal  tuberculosis  has  peculiarities,  not  l)ecause  it  is 
tuberculosis,  but  because  it  is  fcetal.  It  is  unnecessary  to  do  more 
than  enumerate  the  peculiarities.  In  the  Jirst  place,  fcetal  tubercle 
is  not  pulmonary  tuliercle.  In  the  cases  in  which  definite  tubercular 
lesions  are  i)resent  they  are  rarely  found  in  the  huigs,  and  even  when 
they  are  met  with  in  these  organs  they  are  ipiite  discrete.  Evidentlj' 
this  is  just  what  was  to  be  expected,  for  the  lungs  are  not  in  the 
direct  line  of  bacillary  invasion  of  the  fcetal  body,  neither  is  the 
circulation  in  the  lungs  at  all  active.  On  tlie  other  hand,  the  liver 
is  in  direct  communication  with  the  mnbilical  avenue  of  approach, 
and  therefore  it  is  to  be  expected  that  in  it  and  in  the  neighljouring 
glands  there  will  be  tubercular  lesions.  As  a  matter  of  fact,  the 
liver  is  frecpiently  affected;  but  it  has  to  be  noted  that  there  are  not 
a  few  exceptions.  Possibly  this  is  to  lie  explained  by  the  fact  that 
the  invading  germs  may  pass  direct  to  the  iieart  by  the  ductus 
venosus  without  traversing  the  liver.  From  a  study  of  the  reconlcd 
cases,  it  would  appear  that  tuljercle  germs  may  reach  the  fcetus  iu 
large  numbers ;  when  they  do  so  the  lesions  are  generally  wide- 
spread :  they  may,  on  the  other  hand,  be  few  in  number,  and  then 
the  lesions  are  commonly  localised,  iu  the  suprarenals,  in  the  cere- 
bellum, in  the  liver,  spleen,  and  indeed  in  all  the  glands,  and  rarely 
in  the  bones  and  serous  membranes.  In  the  second  place,  such  cases 
as  that  of  Auche  and  Chambrelent  {loe.  cit.)  seem  to  prove  that  ■ 
the  foetal  tissues,  far  from  being  unsuitable  soil  for  the  growth  of 
tubercle  bacilli,  are  peculiarly  fitted  for  their  reception  and  develo))- 
ment.  In  the  liver  and  spleen  they  have  been  found  in  such  nundicrs 
as  to  rival  the  lesions  of  "avian  tuberculo.sis."  This  conclusion,  if 
warranted  Ijy  further  research,  has  a  most  important  liearing  u]iiin 
the  theory  of  Baumgarten.  In  the  third  place,  it  may  turn  out  that 
iu  fcetal  tubercular  lesions  giant  cells  are  wanting;  Imt,  iu  the 
absence  of  a  large  nund^er  of  observations,  it  is  not  safe  to  make  this 
generalisation.  In  the  fourth  place,  tubercle  bacilli  may  be  ]n'esent' 
in  the  foetal  organs  in  large  numbers  without  the  development  of  the' 
characteristic  lesions  of  postnatal  tubercle ;  this  is  the  .so-called' 
bacillosis  without  lesions,  and  it  may  be  due  to  the  termination  ol 
antenatal  life  liefore  the  lesions  have  had  time  to  form.  Inf'antf 
who  show  bacillosis  may  be  apparently  perfectly  viable  and  well 
developed  ;  on  the  other  hand,  the  exiierimental  work  of  A.  Charrir 
(Joitrn.  de phijsiol.  ct  dc  path,  gen.,  i.  82,  1899)  and  others  would  seen 
to  prove  that  the  offspring  of  guinea-pigs  which  have  lieen  inoculatec 
with  tubercle  grow  slowly,  have  a  low  temperature,  and  suffer  fron 
lesions  in  the  liver,  thyroid,  and  sometimes  in  the  kidneys.  In  thi 
latter  case,  however,  the  foetuses  do  not  necessarily  contain  tnbercl' 
bacilli.     It  is  quite  possible  that  these   hepatic,   renal,   and   othe 


BAUMGARTEN'S   THEORY  213 

clianges  are  the  result  nf  the  transmission  of  toxines,  and  not  of  the 
bacilli  themselves  ;  a  similar  supposition  has  been  made  with  regard 
to  typhoid  fever  occurring  in  pregnancy.  It  may  therefore  be  said 
that,  in  the  fifth  place,  foetal  tubercle  may  take  on  characters  not  at 
first  recognisable  as  in  any  way  tubercular. 

Baumgarten's   Theory. 

Any  discussion  of  fcetal  tubercle  would  manifest!}^  be  incomplete 
without  a  reference  to  the  views  advanced  by  Baumgarten  {Ccntrlhl. 
f.  d.  mcd.  Wissensch.,  xix.  274,  1881 ;  Samml.  Min.  Vortr.,  No.  218, 
"l882  ;  Ztschr.f.  klin.  Mcd.,  vi.  61,  1883).  This  author  was  struck  by 
tlie  fact,  which  has  engaged  many  other  workers  in  this  field  of  study, 
that  while  tuberculosis  is  evidently  and  very  frequently  transmitted 
from  parents  to  children,  it  is  couimouly  not  till  late  childhood  or 
early  adult  life  tliat  distinct  signs  and  symptoms  begin  to  appear. 
In  order  to  retain  the  idea  that  the  tulsercle  of  the  ascendants  was 
transmitted  to  theii-  descendants,  and  to  bring  it  into  harmony  with 
the  long  period  of  apparent  immunity  which  intervenes  between  birth 
and  the  appearance  of  the  disease,  Baumgarten  was  led  to  formulate 
the  theory  of  the  latency  of  the  germ.  He  believed  that  germs  are 
carried  to  the  unborn  infant  either  through  the  placenta  or  by  the 
ovum  or  spermatozoon  (at  the  time  of  conception) ;  that  these  some- 
times, possibly  when  very  numerous,  set  up  distinct  tubercular 
lesions  in  the  foetus,  or  lead  to  the  develojiment  of  the  rare  infantile 
form  of  tuberculosis ;  that  most  often  they  are  few  in  number,  and 
remain  in  the  foetal  tissues  and  organs  in  a  sort  of  larval  state  till 
birtli,  and  for  a  short  time  thereafter ;  that  the  larval  stage  is 
succeeded  liy  one  of  semi-activity,  in  which  tubercular  foci .  are 
formed  ;  and  that  these  foci  may  long  remain  latent,  existing  simply 
in  the  anatomical  and  not  in  the  clinical  sense,  but  may  at  some 
time  or  another  give  rise  to  active  tubercular  manifestations.  It  was 
thought  that  the  tubercular  foci  were  most  often  to  be  found,  if 
looked  for,  in  the  bones  and  glandular  system.  Now,  modern  research 
has  revealed  some  facts  which  lend  support  and  some  which  go  to 
discredit  this  theory  of  latency  of  the  germ  as  stated  by  Baumgarten. 
For  instance,  it  is  now  known  that  tubercle  bacilli  may,  in  small 
numbers  at  any  rate,  gain  access  to  the  fretus  through  the  placenta, 
and  that  at  the  time  of  birth  they  may  have  produced  no  recognisable 
tubercular  lesions.  On  the  other  hand,  there  is  little  or  no  evidence 
to  support  the  conclusion  to  which  Baumgarten  was  driven,  that  the 
tissues  of  the  fa?tus,  on  account  of  their  great  vitality,  restrain  or 
altogether  prevent  the  growth  of  the  germs  of  tubercle.  Such  cases 
as  that  reported  by  Auche  and  Chambrelent  {loc.  cit.),  and  such 
experiments  as  those  of  Sanchez-Toleilo  (Arch,  dc  niM.  exp^r.  et  d'anat. 
path.,  i.  503,  1889)  and  A.  Gartner  {Ztschr.  f.  Hyy.  ti.  Infedions- 
krankh.,  xiii.  101,  1893),  show  no  special  resistance  of  the  foetal 
tissues;  indeed,  it  has  already  been  stated  that,  when  tubercle  bacilli 
reach  the  fa?tal  organs,  they  apparently  have  found  a  soil  very 
suitable  for  their  growth,  and  may  soon  be  as  numerous  as  they  are 


214  ANTKNATAI.    I'ATHOI.OdV    AM)    llYCilKNE 

in  '•avian  tuliuic-ulosis."  There  are  oLlier  dittieullie.s  in  the  way  of  an 
acceptance  of  Baumgarteu's  theory ;  and  it  nnist,  I  think,  be  fully 
conceded  that  the  great  number  of  cases  of  tuberculosis,  both  in 
children  and  adults,  are  caused  by  the  invasion  of  the  organism  by 
germs  in  postnatal  and  not  in  antenatal  life.  The  cases  of  true 
congenital  tubercle,  with  or  without  lesions,  are  rare  ;  and  there  is  no 
good  reason  to  believe  that  germs  entei-  tlie  foRtus,  and  after  a  ]ieriod 
of  latency  lead  to  antn-infection  in  adult  life. 

Non-Tubercular  Manifestations  of  Antenatal    Tubercle. 

I  have  already  referred  to  the  occurrence  of  pathological  ccm- 
ditions  in  the  ofl'spring  of  tubercular  women,  conditions  which  are 
not  tubercular  in  the  usual  sense  of  the  word ;  these  I  have,  for 
want  of  a  better  name,  called  the  non-tubercular  manifestations  of 
antenatal  tubercle.  I  do  not  defend  the  nomenclature;  but  I  draw 
the  reader's  attention  to  the  phenomena,  fur  they  are,  to  my  mind, 
of  a  very  special  importance. 

I  have  at  various  times  met  with  the  following  cases.  There  was 
the  instance  of  foetal  ascites  and  distension  of  the  bladder  in  the 
offspring  of  a  tubercular  woman,  which  I  recorded  (197)  in  the  Edin- 
hurrjh  Obstetrical  Society's  Transactions  in  1897.  Into  tliis  case  and  its 
meaning  I  do  not  propose  to  enter,  f(.)r  unfortunately  no  examination 
for  the  tubercle  bacillus  was  made.  It,  however,  directed  my  atten- 
tion towards  the  occurrence  of  ftetal  diseases,  not  necessarily  of  a 
tubercular  type,  in  the  offspring  of  tuliercular  parents.  The  second 
case  was  more  immediately  important  and  striking.  It  was  as 
follows : — 

On  January  2,  1899,  I  saw  with  my  friend.  Dr.  John  Stevens,  an 
interesting  case  of  congenital  anonuily  of  the  knee-joint.  The  patient 
was  a  male  child,  eleven  months  old,  the  offspring  of  the  third 
pregnauey  of  a  woman  whose  two  earlier  gestations  had  also  ended  in 
the  birth  of  males,  but  well-formed  anil  healthy  males.  There  was 
one  fact,  however,  about  the  third  pregnancy  which  calls  for 
immediate  notice ;  it  was  that  the  mother  during  it  was  in  an 
advanced  stage  of  pulmonary  tuberculosis.  Obstetrically,  it  ]nu'sued 
a  normal  course ;  the  infant  was  carried  to  the  full  term  and  born 
without  artificial  assistance.  Soon  after  liirth  it  was  noticed  tliat  tlie 
uifaut,  who  was  healthy  in  appearance  and  not  malformed,  had  tlie 
power  of  causing  a  curious  change  in  his  right  knee-joint.  "When  the 
right  foot  was  pressed  against  the  left  leg,  and  more  particularly 
during  struggling  and  crying,  a  slight  creaking  sound  was  heard,  and 
it  was  then  evident  that  a  dislocation  outwards  of  the  right  knee  had 
occurred.  This  phenomenon  happened  frequently,  .sometimes  very 
many  times  in  succession,  and  as  the  infant  grew  older  it  seemed  as 
if  he  derived  a  certain  amount  of  satisfaction  from  this  voluntary  and 
transitory  dislocation.  When  I  saw  him  he  was  eleven  months  old, 
and  was  beginning  to  stand,  and  could  bear  his  whole  weight  upon 
the  right  foot.  Notwithstanding  this,  he  was  still  able  to  dislocate 
the  knee,  without  a]ipareiitly  causing  any  inconvenience  to  himself. 


ANTENATAL  TUBERCLE  215 

By  seizing  the  right  leg  and  pressing  the  head  of  the  tibia  outwards, 
I  found  I  could  cause  the  luxation,  and  reduce  it  again  quite  easily  and 
without  distressing  the  child.  The  two  knees  did  not  appear  to  be 
dissimilar,  but  the  dimple  over  the  external  condyle  of  the  femur  in 
extension  of  the  joint  seemed  to  be  more  marked  on  the  right  side. 
All  the  movements  of  the  knee  took  place  quite  naturally.  Careful 
palpation  during  the  production  of  the  dislocation  discovered  that 
the  head  of  the  tibia  passed  outwards  to  a  slight  extent  at  the  same 
time  as  the  distinct  click  was  heard.  There  was  no  clubfoot ;  indeed, 
the  boy  was  normal  in  every  way,  save  for  the  recurrent  dislocation 
of  the  knee.  This  was  the  state  of  things  in  January,  and  it  was  my 
wish  that  as  soon  as  he  was  able  to  walk  the  child  should  be  fitted 
with  a  retentive  apparatus  to  fix  the  joint  and  allow  of  retraction  of 
the  ligaments,  for  it  was  evident  that  there  was  some  relaxation  of 
the  ligamentous  structures,  and  especially  of  the  crucial  ligaments. 
But  as  the  weeks  passed  it  was  noticed  that  as  he  began  to  stand  and 
walk  the  dislocation  occurred  with  diminishing  fre(piency.  At  the 
age  of  sixteen  months  there  was  power  of  walking,  and  the  dislocation 
no  longer  happened,  and  even  considerable  pressure  did  not  produce  it, 
and  manifestly  there  was  no  need  to  make  excessive  pressure.  The 
mother,  however,  had  succumbed  to  the  phthisical  condition  from 
which  she  was  suffering,  her  infant  remaining  well  and  healthy. 

This  case  suggests  the  question  whether  the  state  of  the  infant's 
knee-joint  was  iu  any  way  the  result  of  the  mother's  tuberculosis. 
Unfortunately  the  placenta  was  not  available  for  microscopic 
examination.  It  is  only  right  to  state  tliat  the  father  of  tlie  child 
was  the  subject  of  n;evoid  swellings  of  the  eyelids  and  of  mevi  upon 
the  scalp  and  back ;  these  were  congenital  in  their  nature.  The  case 
was  fully  reported  in  1899  (105-107). 

So  much  was  I  impressed  with  the  association  of  foetal  malforma- 
tion and  disease  with  tubercle  in  the  parents,  that  when,  in  the 
Septemlier  of  1900,  I  had  charge  of  the  Eoyal  Maternity  Hospital, 
Edinljurgh,  I  had  under  my  care  a  parturient  woman  with  phthisis 
of  both  lungs,  I  caused  careful  search  to  lie  made  for  malformations 
or  anomalies  in  the  infant  to  which  she  gave  birth.  It  was  found 
that  the  child  had  webbed  toes. 

These  observations  do  not  of  course  stand  alone.  The  occurrence 
of  malformations  and  strixctural  peculiarities  iu  the  children  of 
phthisical  parents  has  lieen  known  for  years,  and  V.  Hauot  {Gaz. 
hchd.  dc  med.  ct  chir.,  xliii.  265,  1896)  has  called  it  heteromorphic 
tubercular  heredity.  Various  dystrophies  have  been  noted,  such  as 
minor  malformations  of  the  cranium,  hernias,  ectopia  of  the  testicle, 
malformations  of  the  heart  and  great  vessels,  lobulation  of  the  liver, 
congenital  dilatation  of  the  oesophagus,  infantilism,  congenital 
dislocation  of  the  hip,  hare-lip  and  palatal  defects,  deaf-mntism,  and 
even  actual  monstrosities  (pseudencephaly,  anencephaly).  In  these 
cases  it  would  ahnost  seem  as  if  the  malformation  or  anomaly  had 
taken  the  place  of  the  truly  tubercular  lesion.  Hanot  {loc.  cit.),  for 
instance,  suggests  that  congenital  atresia  of  the  pulmonary  artery, 
which  he  has  noted  in  the  descendants  of  tubercular  parents,  may 


216  ANTKNATAL    I'ATHOLOCIY    AND    HYGIEXE 

represent  tlie  whole  ol'  the  transmitted  tendency ;  the  cardiac  mal- 
formation of  the  oilsjirinj^  of  tubercular  parents  may  then  indicate 
not  a  proneness  to  become  tubercular,  but  an  innuunity  against 
tuberculosis  1  Without  going  so  far  as  Hanot  does,  it  may  be 
conceded  that  there  is  in  all  probability  the  relation  of  cause  and 
elfect  between  the  tubercle  in  the  parents  and  the  malformations  and 
dystrophies  in  the  children.  It  may  also  be  said,  and  in  this  respect 
the  evidence  is  against  Hanot's  view,  that  sometimes  foetal  tuliercle 
may  co-exist  with  a  malformation;  Sarwey's  case  (-4?-c/;./.  Gijnack., 
xliii.  162,  1892),  was  that  of  a  foetus  which  had  a  large  meningocele 
and  cleft  palate,  and  at  the  same  time  showed  distinct  tuliercular 
lesions  in  the  liodies  of  the  cervical  vertebra'.  Too  much  must  not, 
however,  be  concluded  from  Sarwey's  observation,  for  in  it  the  father 
alone  was  tubercular,  and  the  tuliercular  nature  of  the  fcetal  lesions 
was  not  estaljlished  beyond  all  doubt.  G.  Keim  {I'Ohdi'triqv.c,  iv. 
4-73,  1899),  has  recently  reported  a  remarkable  case  in  which  the 
twins  of  a  tubercular  mother  were  of  the  same  sex,  and  yet,  while  one 
was  normal  in  appearance,  the  other  showed  malformations  of  the 
lower  limbs.  This  whole  question  of  the  non-tubercular  manifesta- 
tions of  antenatal  tubercle  must  be  for  the  meantime  left  in  a  chaotic 
state.  Its  meaning  is  not  clear  ("  bleibt  unklar  "),  although  it  may 
be  conjectured  that  the  malformations  are  due  to  tuliercular  toxinic 
products  reaching  the  embryo  (bacillary  toxa-mia),  and  disturliing 
normal  embryogenesis.  Possibly  such  experiments  as  those  made  by 
G.  Carriere  (Arch,  de  mid.  exper.  et  d'anat.  2)ath.,  xii.  782,  1900),  in 
which  the  young  of  tubercular  guinea-pigs  showed  various  morbid 
states,  and  were  more  easily  tuberculisable,  may  j^et  throw  light 
upon  the  matter.  They  show,  apparently,  that  when  the  disease 
itself  is  not  transmitted  from  parent  to  child,  a  sort  of  weakened 
state  may  be  passed  on,  which  both  before  and  after  birth  may 
lead  to  morbid  developments,  arrests  of  formation,  and  arrests  of 
function. 

The  Antenatal  Factor  in  the  Prophylaxis  of  Tubercle. 

From  what  has  been  written,  it  is  evident  that  the  antenatal  side 
of  the  problem  of  the  prevention  of  tubercle  cannot  be  neglecte<l. 
While  it  is  clear  that  foetal  tul)ercle  with  lesions  is  very  rare,  and 
while,  therefore,  the  danger  of  an  infant  being  born  already  att'ected 
with  tubercle  is  slight,  yet  there  are  associated  dangers  which 
are  not  slight,  and  which  we  cannot  afford  to  neglect.  There  is 
evidence  that  the  offspring  of  tubercular  women  are  born  not  in- 
frequently with  dimuiished  powers  of  resistance,  and  even  with 
various  malformations,  some  of  which,  such  as  cardiac  anomalies,  act 
as  veritable  disalulities.  These  may  be  due  to  the  transmission  to 
the  ftetus  in  utero,  of  bacilli  or  of  their  toxinic  products.  Xo  doubt, 
in  such  weakened  organisms  the  advent  of  tubercle  bacilli  from  the 
outside  in  postnatal  life  will  be  less  likely  to  be  eflectually  resisted ; 
in  this  sense  it  may  be  said  that  the  tendency  to  become  tubercular 
is  transmitted;  it  is  not,  however,  a  tendency  specially  to  liecome 


FCETAL   SEPSIS  217 

tubercular,  hut  a  teiuleiicy  to  yield  to  the  onslaughts  of  all  forms  of 
pathogenic  organisms  and  their  associated  toxines.  It  may  then  be 
concluded  that  it  is  a  danger  to  the  unborn  to  have  a  tubercular 
mother ;  but  the  danger  is  much  lessened  if  there  be  a  healthy 
placenta. 

Foetal  Sepsis. 

As  yet  comparatively  little  is  known  of  the  transmission  from 
mother  to  foetus  of  the  specific  organisms  of  sepsis ;  but  it  cannot  he 
doubted  that  a  most  important  part  of  antenatal  pathology,  that 
dealing  with  fcetal  sepsis,  yet  remains  to  Ije  investigated.  Reference 
has  already  been  made  to  the  discovery  of  streptococci  in  the  fcetus 
of  a  woman  suffering  from  erysipelas  (Bidoue's  case),  and  indications 
are  not  wanting  of  other  instances  of  a  similar  or  allied  kind.  Thus 
G.  Eicker  {Centrlhl.f.  allg.  Path.  u.  path.  Anat.,  vi.  49,  1895)  records 
two  cases  in  which  the  streptococcus  pyogenes  was  found  in  the 
human  fojtus ;  in  one,  the  mother  died  of  diphtheria  at  the  sixth 
mouth  of  pregnancy,  and  the  micro-organism  was  found  in  her  body, 
in  the  placenta,  and  in  the  liver  of  the  fcetus,  although  the  foetus  and 
placenta  showed  nothing  abnormal  otherwise ;  in  the  second  caise  the 
mother  suffered  from  an  abscess  of  the  arm,  which  proved  fatal  after 
the  deliver}'  of  a  dead-born  infant,  which  showed  the  streptococcus  in 
the  blood  of  the  umliilical  vein.  Cases  of  true  fcetal  sepsis  must  not 
of  course  be  confounded  with  the  comparatively  much  commoner 
instances  of  intranatal  infection  of  the  foetus ;  when  septic  germs  are 
present  in  the  mother's  vagina,  they  may,  during  labour,  and  especially 
dm-ing  prolonged  labour,  gain  access  to  skin  wounds,  or  to  the  eyes,  or 
to  the  mouth  and  lungs  of  the  infant  passing  through  the  canals  ;  they 
may  set  up  ophthalmia,  or  pneumonia,  or  septic  cutaneous  conditions, 
but  these  are  not  truly  fcetal  in  origin.  Even  the  cases  in  which,  on 
account  of  premature  rupture  of  the  mend^ranes,  germs  gain  access 
to  the  fcetus  while  it  is  in  the  uterus  (Queirel,  Marscille-mtkl.,  p.  124, 
July  15,  1895),  ought  to  be  separated  from  those  in  which  the 
infection  takes  place  Ijy  the  placental  route,  the  uterus  being  still 
a  closed  cavity.  In  addition  to  Eicker's  cases,  which  have  been 
referred  to  above,  Bonnaire  {I'Olstctrique,  iv.  473,  1899)  has  recorded 
three  instances  in  which  streptococci  seem  to  have  passed  from 
mother  to  foetus  by  the  placental  route ;  in  one  of  these  the  mother 
died  of  eclampsia  after  ha^'ing  expelled  a  dead  fcetus ;  the  maternal 
blood  and  meningeal  pus  gave  a  pure  culture  of  streptococcus 
pyogenes,  and  the  cerebro-spinal  fluid  of  the  infant  gave  a  culture 
rich  in  streptococci.  The  article  by  AVidal  and  Wallich  {Compt. 
rend.  Soc.  dc  bioL,  10  s.,  v.  266,  1898)  is  also  of  interest  in  this 
connection.  The  staphylococcus  also  sometimes  passes  to  the  foetus, 
as  has  been  shown  by  Fraenkel  and  Kiderlen  in  their  case  already 
referred  to  (vide  p.  200) ;  and  two  or  three  cases  are  on  record  in  which 
the  bacteriimi  coli  seems  to  have  been  transmitted.  The  passage 
of  the  diplococcus  of  pneumonia  will  be  considered  in  a  separate 
paragraph. 

It  must  be  freely  admitted  that  true  foetal  sepsis  occurs ;  but  it  is 


218  ANTKNA'IAL    I'ATHOLOCJY   AND    IIVdIKNi: 

jiroljably  C(Jiiiparativcly  rare.  It  luay,  as  has  Ijcuii  staled  in  tiie 
description  of  tVrtal  typlioid,  be  met  with  as  a  secondary  and 
associated  infection  in  antenatal  life.  An  interesting  part  of  this 
subject  has  yet  been  liardly  at  all  investigated,  namely,  the  character 
of  septic  lesions  in  the  ftetus.  In  some  of  the  older  works  we  read 
of  purulent  collections  in  the  foetal  tissues  (P.  Ollivier,  Arch,  i/i'n.  de 
mM.,  2  s.,  V.  70,  1834),  and  it  is  possible  that  these  may  liave  been 
the  result  of  ftetal  sepsis.  IVIore  recently  Palazzi  (Ann.  di  osfct.  r 
r/incc,  xxiii.  558,  1901)  has  met  with  two  cases  of  abscess  in  the 
foetus,  but  in  each  instance  the  mother  was  quite  healthy.  Foetal 
endocarditis,  also,  and  hepatitis  may  be  consequences  of  the  invasion 
of  the  foetal  body  by  the  umbilical  avenue.  It  may  be  surmised,  in 
addition,  that  septic  conditions  of  the  mother  may  produce  morbid 
states  in  the  fa;tus  which  are  not  themselves  evidently  septic,  such  as 
delayed  develoj^ments,  congenital  weakness,  and  tendencies  to  defect- 
ive body  metaliolism  of  various  kinds.  At  any  rate,  the  experience 
which  has  been  gained  from  the  study  of  the  dystrophies  of  fcetal 
tuberculosis  and  syphilis  would  almost  warrant  us  in  concluding  that 
sepsis  also  has  similar  effects.  It  must  be  freely  confessed,  how- 
ever, that  much  remains  to  be  done  to  elucidate  the  problems  of  foetal 
sepsis.  It  may  be  hazarded,  from  what  is  known  of  allied  conditions 
in  the  new-born  infant,  that  suppuration  is  a  comparatively  rave 
result  of  the  entrance  of  septic  bacilli  into  the  f<etus. 

I  may  close  this  chapter  with  a  few  notes  of  some  diseases  which 
have  only  rarely  lieen  observed  in  the  fojtus,  namely,  epidemic 
cereln'o-spinal  meningitis,  purpura,  pneumonia,  anthrax,  and  rheumatic 
fever. 

Epidemic  Cerebro-spinal  Meningitis  in  the  Foetus. 

In  October  1899,  I  received  a  letter  from  Dr.  11.  B.  H.  Gradwdhl, 
bacteriologist  to  the  St.  Louis  City  Hospital,  U.S.A.,  containing  a 
reference  to  "  a  case  of  epidemic  cereln'o-spinal  meningitis  trans- 
mitted in  utero."  As  the  case  is  probal)ly  uni(pie,  1  give  the  details 
somewhat  fully. 

The  patient  was  a  woman,  aged  31,  seven  months  pregnant,  wlio 
two  days  before  coming  into  hospital  had  begun  to  suffer  from  pain 
in  the  left  ear.  Some  drug  had  Ijeen  injected  into  the  ear  by  a 
medical  man  but  witliout  relief,  and  she  soon  became  comatose.  Ko 
foetal  heart  sounds  could  be  heard,  and  the  fa^tus  could  easily  lie 
pushed  from  side  to  side.  Vaginal  examination  revealed  a  soft 
undilated  os.  Eespirations  were  somewhat  laborious,  and  the  pulse 
was  rapid  (120)  and  weak;  temperature  102°  F.,  pupils  unequal, 
Kernig's  sign  present.  The  head  was  drawn  back,  there  was  hyi'cr- 
a'sthesia  and  photcq)hobia,  and  on  touching  the  spine  or  back  of  the 
neck  the  patient  Wduld  come  out  of  her  coma  for  a  moment  or  two 
and  nnitter  deliriously.  Tachc  a'n'bralc  was  manifest,  and  there  was 
instability  of  the  pni)il.  She  died  undelivered,  and  at  the  necropsy 
the  kidneys  showed  acute  parenchymatous  nephritis,  and  inside  the 
cranium  was  a  typical  meningitis  (an  abundant  purulent  exudation 


F(ETAL   PURPURA  219 

was  scattered  here  and  there  over  the  entire  meningeal  surface, 
especially  at  the  liase),  while  the  same  condition  was  found  upon 
the  cord.  A  seven  months  fa-tus  was  removed  from  the  uterus,  and 
in  it  there  was  an  exact  counterpart  of  the  condition  of  the  maternal 
meninges,  with  perhaps  more  of  a  sero-purulent  exudation  than  a 
purely  purulent  one.  Bacteriological  examination  of  fluid  from  l^oth 
the  maternal  and  fcetal  meninges  revealed  the  presence  of  the  diplo- 
coccus  intracellularis  meningitidis.  The  same  micro-organism  was 
also  separated  in  piu'e  culture  from  the  left  ear  of  the  mother.  Dogs 
inoculated  with  cultures  from  the  maternal  and  foetal  meninges  died 
in  convulsions. 

This  case  occurred  during  an  epidemic  in  which  thirty-four 
persons  were  affected,  and  details  both  of  the  epidemic  and  of  the 
special  case  were  communicated  by  Dr.  Gradw-ohl  to  the  Philaddphia 
Monthly  Medical  Journal  (vol.  i.,  July  and  September,  1899).  In  the 
absence  of  further  mformation  about  epidemic  cerebro-spinal  men- 
ingitis in  the  fa;tus,  the  case  must  stand  alone,  and  it  would  be  rash 
in  tlie  extreme  to  draw  anj'  deductions  from  it. 

Fcetal  Purpura. 

Fcetal  purpura,  like  foetal  cerebro-spinal  meningitis,  would  seem 
to  be  one  of  the  rarest  of  the  diseases  which  may  be  transmitted 
from  the  mother  to  her  unborn  infant.  Some  of  the  cases  which 
have  lieen  repoi'ted  would  seem  to  have  been  the  results  of  the 
traumatism  of  labour,  and  not  true  instances  of  the  purpuric  disease ; 
others  appear  to  have  been  examples  of  haemorrhages  into  the  skin 
developed  after  birth,  as  in  Dr.  Elizalieth  Stow  Brown's  case  {Amer. 
Journ.  Ohst.,x.\u\.  1048, 1885),  in  which  there  was  melajna  neonatonmi 
and  omphalorrhagia,  and  in  which,  also,  there  was  a  family  history 
of  hemophilia.  I  have  recently  met  with  a  case,  which  occurred  in 
the  practice  of  Dr.  W.  H.  Miller  of  Edinburgh,  in  which  the  fcetus 
sliowed  numerous  purpuric  spots  over  the  head,  chest,  and  abdomen. 
There  was,  however,  no  history  of  any  aljnormality  in  pregnancy, 
and  the  mother  was  quite  healthy ;  there  was  no  reason  to  regard 
it  as  true  purpura  hiemorrhagica.  It  may  be  added  that  the  foetus 
showed  also  complete  hypospadias,  with  non-descent  of  the  testicles, 
niaking  the  diagnosis  of  the  sex  douljtful ;  and  there  were  various 
internal  anomalies.  Some  reported  instances  of  purpura  neonatorum, 
such  as  that  described  by  J.  H.  Glenn  at  a  meeting  of  the  Eoyal 
Academy  of  Medicine  in  Ireland  {Med.  Press  and  Circ,  i.,  for  1893, 
p.  587),  are  evidently  cases  of  congenital  syphilis.  If  the  above- 
named  morbid  states  be  excluded,  very  few  genuine  examples  of  foetal 
purpura  remain  in  medical  literature.  Possibly  the  cases  of  Petit 
{Bidl  mid.  du  nord,  2  s.,  xii.  363,  1872)  and  of  Dalziel  {Glasgow 
Med.  Journ.,  5  s.,  xxxii.,  65,  1889)  may  be  regarded  as  such;  cer- 
tainly the  instances  reported  by  Dohrn  {Arch.  f.  Gynaek.,  vi.  486, 
1873-4)  and  by  J.  C.  Diehl  {Ztschr.  f.  Geburfsh.  u.  GynciL,  xli.  218, 
1899)  have  strong  claims  to  be  accepted  as  true  instances  of  the 
transmission  of  purpura  hemorrhagica  from  mother  to  foetus. 


220  ANTENATAL   PATHOLOGY   AND   IIYGIENK 

Diehl's  case  is  ruiMirted  with  coiisiileiiilile  I'ulue.s.s.  The  mother 
was  36  years  of  age,  and  had  six  normal  confinements,  but  no 
abortions,  and  was  pregnant  for  the  seventli  time.  Having  reached 
the  fifth  month,  she  was  attacked  by  pains  and  stiffness  in  the  lower 
limbs,  and  had  to  keep  her  bed.  Slie  gave  birth  to  a  male  fu'tus, 
the  confinement  not  being  accompanied  liy  marked  bleeding.  Soon 
afterwards  she  was  found  to  lie  suffering  from  pur])ura  in  the  skin  of 
the  chest  and  abdomen,  arranged  in  a  somewhat  symmetrical  manner. 
The  urine  contained  blood,  and  the  pulse  was  small,  soft,  and  (|uick. 
She  died  on  tlie  third  day  of  the  puerperium.  The  fcetus,  like 
the  mother,  showed  cutaneous  hicmorrhages,  with  a  symmetrical 
distribution,  but  affecting  only  the  head  and  back;  they  were 
punctiform.  Post-mortem  examination  revealed,  in  the  case  of  the 
mother,  numerous  internal  ha-morrhages  in  the  dura  mater,  under 
the  periosteum  of  the  anterior  wall  of  the  spinal  canal,  in  the  peri- 
aortic tissues,  in  the  left  crus  of  the  diai)hragm,  in  the  tissue  round 
the  urethra,  and  in  the  bladder  wall,  and  elsewhere.  The  ftetus 
showed  irregularly  distributed  hfcmorrhages  iii  the  dura  mater,  in 
the  spinal  canal,  in  the  visceral  layer  of  the  pericardium,  in  the  ' 
peritoneum,  and  on  the  palate;  there  were  no  signs  of  syphilis. 
It  is  unnecessary  to  refer  to  the  microscopical  appearances  of  the 
maternal  and  fcetal  organs ;  Ijut  it  may  1  le  noted  that  in  none  of 
the  organs  (maternal  or  fretal)  were  micro-organisms  discovered, 
although  they  were  very  carefully  looked  for.  Dohrn'.s  case  {loc. 
cit.)  resembled  the  above  in  certain  details,  but  differed  in  the  fact 
that  both  mother  and  infant  recovered ;  the  evidence,  tlierefore,  in 
favour  of  the  diagnosis  of  ftetal  purpura  rested  entirely  upon  clinical 
observation. 

The  case  reported  liy  V.  Hanot  and  Ch.  Luzet  {Arch,  de  mcd.  < 
expir.  ct  d'anat.  imtli.,  1  s.,  ii.  772,  1890)  may  be  referred  to  here,  as 
it  is  apparently  related  to  purpura,  to  cerebro-spinal  meningitis,  and 
to  sepsis.  Briefly  stated,  the  case  was  as  follows : — The  mother  had 
had  a  normal  pregnancy,  which  ended  in  the  expulsion  of  a  dead  ■ 
full-time  foetus.  On  the  day  before  labour  supei'veued,  however,  she 
had  become  comatose,  and  a  number  of  purpuric  spots  had  appeared  ■ 
upon  the  abdomen  and  on  the  upper  and  lower  limbs.  She  died 
two  days  after  her  confinement,  and  at  the  post-mortem  examination 
a  state  of  sub-acute  purulent  cerebro-spinal  meningitis  was  dis- 
covered, with  the  streptococcus  pyogenes  in  the  meningeal  exudation, 
in  the  spleen,  liver,  and  uterus.  Tlie  foetus,  whicli  liad  evidently  not 
been  long  dead,  showed  iro  purpuric  spots  on  the  skin,  but  there  were 
some  hitmorrhages  in  the  pericardial  and  pleural  membranes.  In 
these  petechia^  on  the  pericardium  and  in  the  liver,  the  streptococcus 
pyogenes  was  found.  The  authors  are  of  opinion  that  the  maternal 
cerebro-spinal  meningitis  was  the  ])rimary  source  of  the  bacterial 
infection,  wlience  it  sjiread  to  the  rest  of  the  bodj'  and  through  the 
placenta  to  the  ftetus,  causing  its  infection  and  death  in  utero.  It 
would  seem  that  the  case  is  more  nearly  allied  to  fcetal  sepsis  than' 
to  foetal  purpura ;  but,  after  all,  the  question  may  be  reasonably 
asked,  "What  is  purpura  ? 


FtETAL   PNEUMONIA  221 


Fcetal  Pneumonia. 


Scattered  throughout  inedical  literature  are  reports  of  cases  in 
which  the  fcetus  in  utero  apparently  sutlered  from  pneumonia.  Thus, 
in  B.  C.  Hirst's  observation  (Amcr.  Journ.  Ohst.  xx.  1195,  1887),  a 
prematurely  born  infant,  who  only  lived  twenty-two  hours,  showed 
marked  double  catarrhal  pneumonia,  which  the  author  was  inclined 
to  regard  as  due  to  the  drawing  of  meconium  into  the  lungs  by  the 
making  of  intrauterine  inspiratory  elforts;  the  mother  in  this 
instance  did  not  suffer  from  pneumonia,  but  from  a  large  lumbar 
abscess,  so  that  it  is  probable  that  the  foetal  pneumonia  was  truly 
septic  in  origin.  In  two  cases  of  epidemic  cerebro-spinal  meningitis 
in  pregnancy  observed  by  P.  Foa  and  G.  Bordoni-Ufireduzzi  {Deutsche 
mcd.  Wchmchr.,  xii.  249,  1886),  the  mothers  suffered  from  pneumonia 
in  the  stage  of  red  hepatisation,  and  the  foetuses,  expelled  at  tlie 
fourth  and  sixth  month  respectively,  showed  in  their  l)lood  and  in 
the  liver  the  characteristic  diplococcus  of  pneumonia;  the  micro- 
organism was  discovered  also  in  the  uterine  sinuses  and  in  the  foetal 
portion  of  the  placenta.  These  authors  also  demonstrated  the  passage 
of  the  diplococcus  pneumonite  iir  animals.  As  was  noted  with  other 
transmissible  diseases,  so  with  this,  it  occurs  now  and  again  that  the 
causal  microbe  is  not  found  in  the  foetus:  thus,  in  one  of  E.  Levy's 
cases  {Arch.  f.  cxpcr.  Path.  v.  Pharmakol.,  xxvi.  155,  1889),  there 
was  croupous  pneumonia  in  the  mother,  but  the  diijlococcus  was  not 
found  either  in  the  blood  or  in  the  spleen  of  the  fa^tus  expelled  at 
the  fifth  month  of  antenatal  life.  Several  cases  are  on  record  in 
which  l>oth  mother  and  infant  developed  pneumonia  (M.  Thorner, 
Diss.  Muiichcn,  1884;  Netter,  Compt.  rend.  Soc.  de  bioL,  9  s.,  i.  187, 
1889;  A.  Yiti,  Bifor/na  med.,  vi.  578,  584,  1890;  and  M.  Delestre, 
Comiri.  rend.  Soc.  de  hioL,  10  s.,  v.  150,  1898);  but  the  fostus  some- 
times had  lesions  of  other  pai-ts  as  well  as  the  lungs,  c.ff.  of  the  pleura, 
pericardium,  and  peritoneum.  G.  Carljonelli's  case  {liiv.  di  ostet.  e 
f/inec,  ii.  281,  1891)  was  peculiar  in  that,  while  the  foetus  showed  the 
diplococcus  of  pneumonia  in  the  peritoneal  exudation,  in  the  sisleen 
and  in  the  blood,  the  mother  had  suffered  from  no  infectious  disease 
during  her  pregnancy. 

It  is  evident  that  these  cases  of  ftetal  pneumonia  have  close  con- 
nections with  septic  conditions ;  indeed,  it  may  be  found  desiralile  in 
the  future  to  group  them  with  fcetal  sepsis  rather  than  in  a  division 
by  themselves.  A  reference  to  the  geneicil  principles  which  have 
been  laid  down  with  regard  to  foetal  diseases  will  make  it  plain  wliy 
the  lungs  are  neither  often  nor  exclusively  affected  in  these  cases ;  the 
organs  are  not  in  the  direct  line  of  the  circulation,  and  are  not 
supplied  with  a  large  amount  of  blood.  Of  course,  it  is  not  always 
possible  to  exclude  infection  of  the  foetal  lungs,  which  has  occurred 
during  the  progress  of  labour,  for,  when  early  rupture  of  the  mem- 
branes takes  place,  infected  liquor  amnii  or  vaginal  secretion  may  be 
sucked  into  the  mouth  of  the  infant,  and  reach  the  pulmonary  tissues, 
setting  up  inilammatory  processes  in  them.   Instances  of  this  intranatal 


222  ANTKNATAl.    I'ATHOLOCIY    AND    HY(;1KNK 

mode  ol'  iiifectiiiii  have  1pl'(.'ii  recorded  Ijy  Legry  and  Duljri.sav  {An-h 
de  focoL,  xxi.  599,  1894). 

Foetal  Anthrax. 

Although  the  liacillus  aiithraeis  v.a.s  one  of  the  tir.st  microbes 
whose  passage  through  the  placenta  from  mother  to  fcetvis  was  e.\i)eri- 
mentally  determined  in  animals,  clinical  proof  of  its  transmission  in 
the  case  of  the  human  subject  has  only  been  forthcoming  during 
recent  years.  D.  Morisani  {Morgagni,  xxviii.  523,  188G)  recorded  an 
instance  of  anthrax  in  a  jiregnant  woman,  but  the  fcptus  was  dead- 
born,  and  no  cultures  of  the  liacillus  anthracis  could  be  got  from 
its  tissues ;  on  the  other  hand,  the  pregnant  woman  suHering  from 
malignant  pustule  who  was  seen  by  S.  Eomano  {Mdrgwjni,  xxx.  458, 
1888)  gave  birth  to  a  living  and  healthy  infant.  With  regard  to  the 
case  observed  by  F.  Marchand  {Arch.  f.  jtath.  Anat.,  cix.  86,  1887), 
the  mother  was  found  at  the  autopsj-  to  have  lieen  suffering  from 
anthrax,  and  the  infant  developed  the  same  malady ;  but  the  evidence 
of  intrauterine  transmission  was  defective,  for  the  infection  might 
have  occurred  in  the  act  of  birth,  and,  further,  the  avenue  of  entrance 
of  the  maternal  infection  could  not  be  deteriuined.  In  the  placenta, 
bacilli  were  found  only  in  the  intervillous  spaces.  Over  against  these 
negative  or  practically  negative  results  must  be  placed,  the  three 
remarkable  cases  reported  by  M.  J.  Eostowzew  {Ziachr.  f.  Grhiirtsh. 
u.  Gynak.,  xxxvii.  542,  1897).  These  were  instances  of  malignant 
pustule  attacking  pregnant  women  at  the  eighth,  seventli,  and  fourtii 
months  respectively,  and  proving  fatal  a  few  days  after  the  expulsion 
of  the  uterine  contents.  The  bacilli  of  anthrax  were  found  not  only 
in  the  placental  intervillous  sjaaces,  liut  also  in  the  facial  villi ;  and 
in  one  case  there  were  luemorrhages  into  the  placental  substance, 
while  in  another  there  was  some  necrosis  either  of  the  sj'ncytium 
alone  or  affecting  all  the  component  parts  of  the  villus ;  and  in  the 
necrotic  areas  were  the  bacilli,  Eostowzew  also  found  the  characteristic 
microbes  in  the  licpior  amnii.  With  regard  to  the  fu>tal  tissues  (apart 
from  the  chorionic  villi),  it  was  noted  that  some  bacilli  of  anthrax 
were  to  be  recognised  in  the  blood  and  organs,  but  they  were  few  in 
number,  and  did  not  stain  well  with  reagents ;  possibly  they  were  in 
a  more  or  less  inactive  state,  although,  as  we  have  seen  in  respect 
to  fcetal  tuberculosis,  there  is  no  reason  to  believe  that  the  fu'tal 
structures  have  any  bactericidal  etTect  upon  germs.  From  the  study 
of  Eostowzew's  cases,  it  may  be  considered  that,  while  the  germs  of 
anthrax  had  made  their  way  to  the  foetus,  tliey  had  not  yet  produced 
the  disease  in  it ;  possibly  they  had  not  had  sufhcient  time.  There 
is  a  considerable  literature  dealing  with  the  transmission  of  anthrax 
from  mother  to  fcetus  in  the  case  of  animals  (E.  Perroncito,  Arch.  itcd. 
de  hiol.,  iii.  58,  188:-.:  G.  Sangalli,  E.  Isf.  Lomh.  d.  ,sc  c  Ictt.  Rcndic, 
Milan,  2  s.,  xv.  668,  1882 ;  I.  Straus  and  C.  Ohamberlaud,  Gaz.  held, 
de  inM.,  2  s.,  xx.  167,  1883 ;  V.  Carita,  Gior.  d.  r.  Accad.  di  mcd.  di 
Torino,  3  s.,  xxxi.  349,  1883  ;  ]\I.  Simon,  Ztschr.  f.  Gehiirtsh.u.  Gyncik., 
xvii.  12G,  1889:  W.  Eo.senblath,  Arch.  f.  path.  Anat.,  cxv.  371.  1889; 


\ 


FCETAL  ACUTE   RHEUMATISM  223 

M.  E.  Latis,  Eiforma  vml,  v.  842,  1889 ;  il.  E.  Latis,  L'cHr.  z.  imth. 
Anat.  u.  z.  allij.  Path.,  x.  148,  1891 ;  and  C.  Massa,  lil/urma  iiicd.,  xii., 
pt.  2,  531,  1896);  but,  as  has  been  stated,  the  cases  in  wliicli  a 
pregnant  woman  has  transmitted  the  malady  to  her  unborn  mfant 
are  few  in  number. 

No  instance  has  yet  Ijeen  reported  in  the  human  subject  in  which 
a  mother  has  transmitted  hydrophobia  to  her  foetus ;  but  in  the  pre- 
sence of  the  necessary  conditions  the  occurrence  is  not  to  be  regarded 
as  impossible.  Further,  the  transmission  has  actually  occurred  in  the 
lower  animals;  E.  Perroncito  and  Carita  (Gior.  d.  r.  Accad.  di  med.  di 
Torino,  3  s.,  xxxv.  122,  1887)  inoculated  a  pregnant  rabbit  with 
rabies  in  the  neighbourhood  of  the  fourth  ventricle ;  some  days  later 
the  contents  of  the  uterus  were  expelled,  and  the  animal  died  of 
rabies;  with  the  medulla  oblongata  of  two  of  the  living  foetuses 
which  had  been  expelled,  two  guinea-pigs  were  inoculated;  one  of 
these  remained  healthy,  but  the  other  died,  and  two  other  guinea-pigs 
and  a  rabbit  were  inoculated  from  its  medulla ;  all  the  three  died  with 
the  symptoms  of  rabies.  The  disease  had  therefore  Ijeen  transmitted 
in  the  case  of  some  but  not  of  all  the  foetuses.  G.  Zagari's  experi- 
ments {Gior.  internaz.  d.  sc.  med.,  n.s.,  x.  54,  1888),  however,  gave 
negative  results;  but  Palazzi  {Ann.  di  ostet.  e.  ginec.  xxiii.  570,  1901) 
refers  to  Lisi's  possible  case  of  the  placental  transmission  of  hydro- 
phobia in  a  bitch,  and  gives  details  of  a  somewhat  doubtful  instance 
in  a.  cow  which  had  been  under  his  own  oljservation.  Tiiere  seems 
to  be  no  reason  to  doubt  that,  as  with  other  transmissiljle  maladies,  so 
with  hydrophobia,  its  intrauterine  and  transplacental  transference 
from  mother  to  foetus  may  occasionally  occur. 

In  a  case  of  maternal  diabetes  mellitus,  H.  Ludwig  {Ccntrlhl.  f. 
Gijndk.,  xix.  281,  1895)  found  an  excessive  quantity  of  liquor  amnii, 
and  in  that  amniotic  fluid  were  very  distinct  traces  of  sugar ;  he 
hazarded  the  suggestion  that  possibly  this  might  be  an  instance  of 
foetal  diabetes.  As,  however,  the  infant  was  born  dead,  there  was  no 
opportunity  of  testing  the  suggestion  by  the  results.  Further,  E. 
Eossa  {Centrlbl.  f.  Gynuk.,  xx.  657,  1896),  in  the  following  year  met 
with  a  somewhat  similar  case ;  in  it  the  infant  survived  birth  long 
enough  to  give  an  opportunity  of  m-ine  analysis ;  the  nrine  contained 
no  sugar,  although  the  liquor  amnii  and  the  maternal  urine  did. 

FcEtal  Rheumatic  Fever. 

Sometimes,  although  ^'ery  rarely,  a  pregnant  woman  suffering 
from  acute  rheumatism  give.s  birth  to  an  infant  whose  joints  are 
enlarged  and  tender ;  the  presumption  then  is  that  rheumatic  fever 
has  been  transmitted  from  mother  to  foetus  in  ntero.  The  case 
reported  by  J.  Haig  Ferguson  {Edinh.  Hosj).  Eep.,  i.  608,  1893)  was 
apparently  a  well-estaldished  example  of  this  transmission.  The 
mother  had  twice  suffered  from  rheumatic  fever,  and  was  attacked 
for  the  third  time  at  the  second  month  of  pregnancy;  she  was  ill 


224  ANTENATAI.    PATH()L()(iV    AND    HYdlKNK 

tor  four  iiiontlis,  anil  tliereafter  had  rheumatic  pains  till  the  full 
term;  the  child  at  hirth  was  plump,  but  ciied  when  handled,  ami 
the  knees  and  wrists  and  fingers  were  swollen;  after  hirth  it  rajiidlv 
became  emaciated,  the  swelling  of  the  joints  increased,  and  redness 
and  tenderness  develoiied ;  the  infant  died  when  ten  days  old.  At 
the  autopsy  the  elbows,  wrists,  and  knees  were  found  enlarged,  there 
was  iluid  in  the  knee-joint  and  in  the  pericardium ;  the  bones  were 
not,  however,  diseased.  A  somewhat  similar  case  was  that  seen  liy 
F.  E.  Tocock  (ZftHCf^,  ii.,  for  1882,  j*.  804):  less  than  twelve  hours 
after  birth  the  child's  temperature  was  found  to  be  raised,  the  right 
shoulder  and  elbow  were  swollen,  and  the  skin  covering  them  was 
red ;  since,  also,  these  parts  were  evidently  tender  to  touch,  the 
diagnosis  of  congenital  rheumatism  was  made,  and  salicylate  of  soda 
was  administered :  the  infant  made  a  good  recovery.  Schicfer's 
observation  {Berl.  kiln.  Wcltnschr.,  xxiii.  79,  188G)  closelj'  resembles 
the  foregoing;  in  it,  also,  the  infant  reco\-ered  under  salicylate  nf 
soda.  Possibly  some  of  the  cases  which  have  been  reported  as 
instances  of  rheumatism  in  the  new-born  have  been  truly  antenatal 
in  their  origin ;  l^ut  even  if  they  be  admitted,  the  total  numljer  of 
observations  remains  very  small.  It  must  also  lie  l)orne  in  mind 
that  septic  and  gonorrhoeal  conditions  in  the  new-liorn  may  closely 
simulate  acute  rheumatism.  It  remains  as  an  undouljted  fact  that, 
for  some  reason,  acvite  rheumatism  is  rarely  present  at  birth. 

The  types  of  fo;tal  disease  which  have  been  considered  in  this 
chapter,  and  more  especially  tuberculosis,  will  have  suggested  and 
illustrated  several  new  pathological  jiossibilities  which  arise  when 
a  pregnant  woman  is  the  subject  of  a  malady  which  may  be  trans- 
mitted to  her  unborn  infant.  In  particular,  the  reader  will  have 
learned  that  sometimes  the  disease  itself  may  not  be  transmitted, 
and  yet  the  pathological  state  of  the  mother  may  produce  its  effect 
upon  the  foetus,  and  set  up  in  it  morbid  conditions  which,  for  want 
of  a  better  word,  we  call  dystrophies.  This  special  peculiarity  of 
foetal  pathology  will  be  more  fully  dealt  with  in  the  following 
chapter,  for  it  is  well  demonstrated  in  connection  with  fcetal  syphilis, 
and  with  that  important  malady  the  chapter  has  to  do. 


CHAPTER    XIV 

Types  of  Transmitted  Fu-tal  Diseases  :  FtLtal  Syphilis  ;  Limitation  of  the 
Suliject ;  Definitions  of  Infantile,  Keonatal,  and  Fa'tal  Syphilis ;  Morbid 
Anatomy,  General  and  Special  ;  Dystrophies  of  Antenatal  Syphilis  ;  Patho- 
genesis ;  Nature  of  the  Morbid  Agent ;  Modes  of  Transmission  of  the 
Syphilitic  A'irus  ;  Eft'ects  of  F(jetal  Syphilis  ;  Modifying  Influences  ;  Treat- 
ment. 

F(ETAL  syphilis  is  the  malady  that  most  medical  men  think  of  when 
reference  is  made  to  fcetal  disease.  It  has  been  studied  in  all  its 
aspects  and  at  very  considerable  length  by  a  multitude  of  careful 
observers.  It  has  been  taken  as  the  type  of  antenatal  maladies,  as 
the  typical  disease  of  the  foetus ;  it  may  almost  be  said  that,  to  some 
investigators,  foetal  pathology  and  foetal  syphilis  have  been  synony- 
mous terms.  It  has  comparatively  seldom  been  contrasted  with  the 
other  known  transmitted  maladies  of  the  unborn  infant ;  and  it  has 
scarcely  at  all  been  studied  in  the  light  of  recent  generalisations 
regarding  the  phenomena  and  laws  of  Antenatal  Pathology.  The 
description  of  foetal  syphilis  given  in  this  chapter  is  not  to  be  looked 
upon  as  in  any  sense  an  attempt  to  equal,  far  less  to  surpass,  the  many 
accurate  and  exhausti\-e  accounts  of  the  morbid  anatomy  and  patho- 
genesis of  the  disease  which  have  been  set  forth  by  such  noted 
specialists  as  Colles,  Diday,  Hutchinson,  F.  von  Baerensprung,  Fiirth, 
Fournier,  Kassowitz,  Heubner,  Parrot,  and  Hochsinger.  I  intend 
simply  to  consider  syphilis  as  one  of  the  many  morbid  states  which  may 
be  transmitted  to  the  foetus  in  utero,  albeit  one  of  the  most  important 
of  these ;  to  point  out  in  what  resi^ects  it  agrees  with  or  differs  from 
these  other  transmitted  states ;  and  to  essay  to  show  and  illustrate 
the  manner  in  which  the  malady  obeys  the  laws  which  govern 
Antenatal  Pathology.  To  do  more  than  this  would  be  to  expand 
this  chapter  into  a  volume,  and  so  destroy  the  symmetry  of  this 
Manual  of  Antenatal  Pathology ;  to  do  less,  would  be  to  give  in- 
adequate consideration  to  a  foetal  disease  of  great  importance  and 
with  far-reaching  consequences. 

Limitation   of  the   Subject. 

I  do  not  intend,  save  in  an  indirect  fashion,  to  describe  the 
syphihtic  manifestations  which  first  appear  during  the  second  month 
of  life.  To  them  the  name  of  infantile  syphilis  is  correctly  enough 
given.  They  are  due  in  the  great  majority  of  cases  to  infection  whicli 
has  occurred  before  birtli ;  but  in  a  small  minority  of  instances  they 
15 


22G  ANTl-.NATAI.    I'ATHOI.OC.Y   AND    HYGIENE 

take  tlieir  origin  in  tlit^  iiiUaiialal  or  in  tlio  neonatal  j)eiiod,  and  are, 
therefore,  sometimes  of  the  nature  of  "ac<niired"  syphilis,  albeit  tlie 
acquirement  is  entirely  involuntary  and  "innocent."     Tlie  possiliility 
of  the  acquirement  of  syphilis  during  the  act  of  parturition  has  been 
doubted;   Ijut   some   few   cases  have  been  put   upon   record   {vide, 
L.  D.  Bulkley's  Si/phUis  in  the  Innocent,  p.  170,  1894),  in  which  a 
chancre  ("  at  the  root  of  the  nose,"  "  at  the  inner  angle  of  the  eye," , 
etc.)  appeared  four  weeks  after  birth,  and  could  apparently  l)e  traced 
to    recently   developed    syphilitic    lesions    of    the   mother's  genitals 
(Thiry,  Prcssc  inhl.  hcljjc,  xxxvi.  241,  1884).     Cases,  also,  have  been 
reported  in  whicli  syi)hilis  was  acquired  during  the  neonatal  period, 
either  from  the  nurse  in  lactation  or  from  an  infected  infant.     As  a 
rule,  however,  syphilis  showing  itself  for  the  first  time  in  the  second, 
month  of  life  has  been  transmitted  to  the  infant  before  birth  ;  in  its 
clinical   manifestations  it   differs   from   the    acquired    ftnins   in    the 
absence  of  the  primary  sore  and  initial  glandular  enhirgement,  and 
in  other  minor  details  such  as  the  rarity  of  roseola.     It  is  syphilis 
occurring  in  and  being  modified  by  the  infantile  organism ;    it  has 
characters  which  are  impressed  upon  it  by  the  peculiarities  of  the 
physiology  of  the  infant  {e.g.  its  fatality,  the  nature  of  the  cutaneous 
lesions) ;  and  for  it,  in  my  opinion,  the  name  infantile  sy2}hilis  ought 
to  be  rigidly  reserved.     Like  syjihilis  in  the  adult  it  has  the  power,  iu 
a   very  remarkable  degree,  of  simulating  or  imitating  many  non- 
syphilitic    morbid  processes ;  there  is  scarcely  a  cutaneous  malady 
that  may  not  thus  be  simulated,  and  even  affections  of  the  respiratory 
circulatory,  gastro-intestinal,  and  nervous  systems  may   be  copied 
more  or  less  closely  by  sypliilis.     The  well-known  symptoms  and 
signs  of  the  disease,  as  it  occurs  in  infants,  it  is  not  my  purjiose  tc' 
consider,  they  are  fully  descriljed  in  countless  text-books  and  mono- 
graphs;  l)Ut  I  may  draw  the  attention  of  the  reader  to  the  striking' 
fact  that,  although  the  infant  is  undoubtedly  .syphilitic  at  birth,  thi 
clinical   manifestations  of  the  taint  have  their  appearance  delayei 
until  six  weeks  or  two  months  liave  elapsed.     What   may  be    th(. 
meaning  of  this  period  of  freedom  from  the  external  signs  of  thi 
disease  it  is  iiot  yet  possible  to  determine ;  all  explanations  must  bi 
more  or  less  of  the  nature  of  guesses.     It  is  possible,  of  course,  tha 
the  extrauterine  environment  differs  so  essentially  from  the  intra 
uterine  that  it  takes  some  time  for  the  disease  to  become  eviden 
along  tlie  new  lines  of  development  wliicli  are  imposed  upon  it  b; 
the  new  conditions  which  surround  it.     It  may  be  that  fa?tal  con 
ditions  favour  the  occurrence  of  visceral  lesions,  while  the  infantil' 
environment  predisposes  to  cutaneous  and  respiratory  changes ;  som 
time  is  necessary  before  the  new  jiathological  departure  makes  itsel 
felt.     It  is  possible,  also,  that  anti-syphilitic  treatment  of  the  niothc 
before  her  confinement  may  have  lieneficially  affected  her  fcetus  i 
utero,  and  tlial  this  good  effect  jiersists  for  four  or  five  weeks  aftc 
birth ;  but  this  explanation  utterly  fails  to  meet  the  cases  in  whic 
no  uiercmy  has  Ijeen  given  to  the  mother  in  her  pregnancy. 

Xeithcr  do  I  intend  to  discuss  fully  the  syphilitic  manifestatior 
wliicli  occasionallv  occur  durintr  the  first  month  of  life.     For  them  tli 


NEONATAL   SYPHILIS  227 

teriu  neonatal  si/phi/is  ought  to  be  reserved,  and  tliey  ought  to  be  dis- 
tinguislied  from  the  signs  which  are  actually  present  at  birth  and  to 
which  alone  the  name  fivtal  si/philis  should  be  applied.  Xeonatal 
syphilis  is  comparatively  rare,  that  is  to  say,  the  offspring  of 
syphilitic  parents,  showing  no  external  indications  of  the  taint 
at  birth,  do  not  often  develop  unmistakable  manifestations  of  it 
during  the  first  two  or  three  weeks  of  life.  When,  however,  the 
disease  is  met  with  at  this  period  of  infancy,  it  has  characters  which 
are  to  some  extent  peculiar  to  it  and  which  are  possibly  the  result  of 
the  peculiar  physiological  conditions  which  then  pievail.  I  have 
already  in  Chapter  IV.  dealt  in  some  detail  with  the  physiology  of  the 
neonatal  period,  and  have  emphasised  and  exemplified  the  fact  that 
it  is  essentially  a  period  of  transition,  of  readjustment,  and  alteration 
of  structure  and  more  especially  of  function  to  suit  the  new  environ- 
ment ;  there  is  no  need  for  me  to  enter  again  into  details  at  this 
stage.  Syphilis,  like  other  maladies  which  may  attack  the  new-born 
infant,  has  characters  impressed  upon  it  which  are  the  result  of  the 
special  physiology  of  the  neonatal  period  of  life.  For  instance,  it  is 
very  fatal  and  very  rapidly  fatal,  a  fact  which  is  no  doubt  partly  to  be 
explained  by  the  transitional  nature  of  the  neonatal  economy.  Death 
is  then  due  in  all  probability  to  visceral  lesions,  for  such  infants  come 
into  the  world  already  carrying  in  their  internal  organs  the  structural 
changes  due  to  foetal  syphilis ;  these  changes  were  to  some  extent 
compatible  with  intrauterine  life,  but  they  seriously  interfere  with 
prolonged  extrauterine  existence.  The  only  sign  of  neonatal  syphilis 
may  therefore  be  rapid  death,  apparently  brought  al:iout  by  a  trifling 
cause  but  really  due  to  antenatal  vi.sceral  lesions  which  become  lethal 
under  the  changed  circumstances  which  follow  birth.  There  may 
also,  however,  be  special  signs  of  the  syphilis  of  the  new-born.  Of 
these  perhaps  the  most  distinctive  is  pemjihigus.  The  bulla;  of  this 
cutaneous  affection  may  be  present  at  birth  and  the  disease  be  there- 
fore truly  fojtal ;  but  very  often  they  do  not  appear  until  a  few  days 
liave  elapsed.  It  is  a  striking  fact  that  the  most  marked  cutaneous 
manifestation  of  neonatal  syphilis  should  be  pemjihigus,  but  it  finds 
an  explanation  in  the  loose  attachment  of  the  epidermis  to  the  under- 
lying skin  at  this  period  of  life  and  in  the  resulting  tendency  to 
desipiamation.  Pemphigus  occurs  also  in  the  new-born  as  a  sign  of 
diseases  other  than  syphilis  (e.g.  sepsis),  and  is  then  no  doubt  due  to 
the  same  keratolytic  state  of  the  integument ;  but  the  form  to  which 
I  now  specially  refer  has  peculiarities  of  its  own  due  to  its  syphilitic 
nature.  The  bulke  contain  a  blood-stained  or  purulent  fluid ;  they 
are  large  and  numerous ;  they  have  a  special  tendency  to  affect  the 
palms  and  soles ;  and  after  rupture  they  tend  to  leave  irregular  ulcers 
covered  sometimes  with  a  brownish  or  blood-stained  crust.  In 
syphilis  neonatorum,  then,  pemphigus  is  apt  to  occur  because  the 
subject  affected  is  the  neio-horn  infant,  and  syphilitic  pemphigus  of 
the  new-born  has  special  characters  which  distinguish  it  from  the 
non-syphilitic  variety.  Another  peculiarity  of  neonatal  syphilis  is 
its  hsemorrhagic  tendency.  So  marked  is  this  tendency  in  some  cases, 
that  the  name  Si/iihilis  hcemorrhagica  neonatorum  has  been  introduced 


1 


228  ANTKNATAL    I'ATHOLOGV   AND   HYGIKNK 

(G.  IJelaeiKl,  Deutsche  Zlschr.  f.  prcdt.  Med.,  v.  28'),  :'.01,  1878; 
E.  Petersen,  Vrtljschr.  f.  Dcrmat.,  x.  509,  1883  li  Fischl,  Arch.  f. 
Kinderl:,  viii.  10,  1886-7  ;  F.  Mracek,  Vrtljschr.  f.  Dcrmat.,  xiv.  117, 
1887  ;  etc.),  to  give  expression  to  it.  It  would  seem  (from  Mracek's 
statistics)  that  the  bleeding  most  commonly  occurs  in  the  skin, 
subcutaneous  tissue,  lungs,  and  pleura,  and  less  frequently  in  the 
heart  and  vessels  (adventitia),  brain,  kidneys,  scalp,  liver,  etc. ;  but  it 
may  apparently  take  place  in  any  organ  or  tissue  in  the  body.  It 
may  be  ascribed  in  part  to  the  direct  effect  of  .syphilis  upon  the 
tissues,  and  in  part  to  the  transitional  state  of  the  blood  and  circula- 
tion immediately  after  birth.  Syphilis  attacking  the  new-born  child 
may  also,  like  that  malady  in  infancy  and  later  life,  .simulate  or  imitate 
the  diseases  which  are  to  some  extent  peculiar  to  the  neonatal  state. 
Thus,  there  is  a  syphilitic  neonatal  omplialorrhagia,  a  syphilitic  oedema 
neonatorum,  a  syphilitic  jaundice  of  the  new-born,  a  syphilitic  mehena 
neonatorum,  and  sri  on.  These  morbid  states  are  all  full  of  interest, 
and  they  are,  moreover,  in  a  sense  congenital,  being  due  to  a  specific 
infection  which  has  occiu'red  before  birth  ;  Init,  as  has  lieen  staled 
above,  they  do  not  fall  to  be  considered  under  the  heading  of  fotui 
syphilis  properly  so  called. 

The  name  fcetal  syphilis  ought,  in  my  opinion,  to  be  limited  to 
the  pathological  changes  which  are  produced  in  the  organs  and 
tissues  of  the  unborn  infant  during  the  foetal  period  of  antenatal  life, 
a  period  wiiich  lasts,  as  will  be  remembered,  from  the  sixth  to  the 
fortieth  week.  As  will  be  seen  immediately,  most  of  these  change-^ 
are  of  the  nature  of  diseases,  but  some  few  of  them  are  more  correctly 
to  be  regarded  as  deformities.  The  latter  find  an  explanation  in  the 
fact,  to  which  reference  has  already  been  made  elsewhere  (p.  10),  that 
all  the  foetal  organs  have  not  completed  their  development  when 
they  reach  the  beginning  of  the  foetal  period  :  the  syphilitic  virus 
acting  ujion  them  in  their  embryonic  state  will,  it  may  lie  supposed, 
produce  in  them  malformations  rather  than  diseases.  It  is  in  this 
way  that  some  of  the  so-called  dystrophies  of  foetal  syphilis  are 
produced.  Theoretically,  foetal  syjihilis  ought  to  lie  sepai-ated  from 
what  may  be  called  emlnyonic  and  germinal  syphilis.  It  is  very 
probable  that  syphilis  acting  upon  the  organism  in  its  embryonic 
period  of  antenatal  life  produces  changes  of  a  very  different  kind 
from  those  met  with  in  the  fcetal  period.  It  may  ultimately  he 
found  that  the  former  are  of  the  nature  of  monstrosities  and  malforma- 
tions rather  than  of  diseases  in  the  strict  sense  of  the  word.  It  is 
not,  however,  in  the  meantime  possible  to  carry  out  in  practice  this 
separation  of  the  phenomena  of  fcetal  from  the  phenomena  of 
embryonic  and  germinal  syphilis  ;  with  fuller  knowledge  it  may  yet 
be  accomplished. 

I  have  thus  indicated  certain  Umitations  of  the  suliject  to  be 
considered  in  this  chapter;  Imt  it  must  not  be  forgotten  that  there 
is  another  aspect  of  the  matter.  It  is  necessary  to  bear  in  mind  that 
when  sypliilis  attacks  the  organism  in  the  fcetal  perioil,it  attacks  not 
only  the  foetus  but  also  the  so-called  foetal  appendages,  namely,  the 
placenta,  membranes,  cord,  and  liijuor  amnii.     There  is,  therefore,  in 


PATHOLOGY   OF   FCKTAL   SYl'UlLIS  229 

this  direction  an  expansion  of  the  meaning  of  the  term  fcctal  syphilis. 
Although,  in  my  classification  of  fa'tal  morbid  states  (p.  175),  I 
have  placed  diseases  and  morbid  conditions  of  the  fcetal  annexa  in  a 
group  by  themselves,  it  is  not  wise  to  insist  too  strictly  upon  this 
separation ;  and,  as  a  matter  of  expedience,  it  will  be  best  in  the  case 
of  foetal  syphilis  to  neglect  it  altogether. 

Morbid  Anatomy  of  Foetal  Syphilis. 

Of  the  vexed  question  of  the  channels  by  which  the  syphilitic 
virus  reaches  the  ftetus  in  utero  something  will  be  said  ere  long ;  but, 
in  the  meantime,  I  proceed  upon  the  assumption  that  fcetal  infection 
with  syphilis  is  generallj'  transplacental.  I  do  not  doubt  that 
syphilis  in  the  father  may  produce  certain  effects  upon  the  fcetus 
through  the  fertilising  spermatozoon  and  that  syphilis  in  the  mother 
may  act  upon  the  ovum  in  the  ovary  and  the  emliryo  in  the  uterus  ; 
I  do  not  deny  the  possibility  of  sperminal  and  germinal  infection 
leading  to  syphilitic  manifestations  in  the  fcetus,  liut,  on  theoretical 
grounds,  I  regard  it  as  unlikely ;  the  consideration  of  these  matters, 
however,  can  be  more  properly  taken  up  after  the  morbid  changes 
met  with  in  the  f(etus  have  l>een  dealt  with.  It  is  provisionally 
imderstood,  then,  that  the  fa?tus  takes  syphilis  from  the  mother 
through  its  vascular  placental  connections,  and  rarelj',  perhaps, 
through  the  medium  of  the  liquor  amnii.  What,  now,  are  the 
pathological  changes  which  may  be  found  in  the  fcetus  at  the  time 
when  it  is  expelled  from  the  uterus  ? 

General  statement. — Fcetal  syphilis,  being  a  fcetal  disease,  will  be 
subject  to  the  laws  that  govern  fcetal  pathology.  What  these  laws 
are,  a  reference  to  Chapter  XI.  will  show.  For  instance,  the  intra- 
uterine environment  will  modify  the  morbid  changes  which  occur  as 
the  result  of  syphilitic  infection;  the  cutaneous  changes  will  be 
slightly  marked  or  al)sent  altogether,  and  the  post-mortem  alterations 
(when  fcetal  death  occurs)  will  l)e  those  due  to  syphilis  associated 
with  those  due  to  the  aseptic  surroundings.  Again,  the  placental 
factor  will  have  its  influence ;  if  we  may  judge  by  analogy,  it  may  be 
said  that  the  placenta  will  in  some  instances  keep  back  the  syphilitic 
poison  (microbic  or  toxinic)  and  so  save  the  fcetus  from  syphilis ;  in 
other  cases,  possibly  on  account  of  placental  lesions,  it  will  allow  it  to 
pass,  and  then  the  fcetal  tissues  will  lie  attached  in  the  manner  and 
order  which  are  peculiar  to  infections  arriving  by  the  umbilical  avenue ; 
in  yet  other  cases,  the  placenta  will  itself  become  seriously  pathological, 
and  this  will  entail  not  fcetal  disease  so  much  as  fcEtal  death ;  and 
finally,  the  foetus  may  become  infected  through  the  placenta  and  then 
die  on  account  of  lesions  in  the  placenta.  From  the  great  frequency 
of  intrauterine  death  in  cases  of  maternal  syphilis,  it  may  lie  con- 
cluded that  the  placenta  acts  most  often  in  the  two  last-named  ways. 
It  must,  also,  be  borne  in  mind,  in  considering  the  morljid  anatomy 
of  fcetal  syphilis,  that  some  of  the  changes  present  may  be  the  results 
of  the  action  of  syphilis  upon  the  organism  in  the  embryonic  or 
germinal  epochs  of  antenatal  life ;  all  that  is  seen  in  the  fcetus  at 


230  ANTRXATAI,   PATHOI.OCIY   AND    HYGIENE 

liirtli  is  nut  necessarily  the  result  of  causes  acting  in  the  fietal 
period;  this  statement  applies  with  special  force  to  what  are  called 
the  syphilitic  dystrojihies. 

Special  morbid  anatomy. — Our  knowledge  of  the  morbid  anatomy 
of  the  various  organs  and  tissues  in  fcetal  syphilis  has  heen  derived 
from  the  study  of  foetuses  born  either  dead  or  alive,  at  or  (more 
frequently)  before  the  full  term  of  intrauterine  existence.  In  many 
details  it  is  unsatisfactory,  fur  next  to  nothing  is  known  of  the  initial 
stages,  and  the  changes  due  solely  to  intrauterine  death  have  been 
persistently  confounded  with  those  caused  purely  by  the  disease. 
Nay  more,  histological  conditions  of  the  organs  which  are  normal  in 
the  ftetus  have  been  described  as  due  to  the  syphilitic  poison.  I  shall 
liegin  my  consideration  of  these  changes  with  the  description  of  them 
as  they  are  found  in  the  placenta  and  umbilical  cord,  for  the  former 
is  the  most  important  organ  that  the  fcctus  has,  and  by  its  pathological 
state  no  doubt  much  is  determined. 

The  2^l(<'Ci'nfa. — Alterations  in  the  structure  of  the  ])lacenta  in 
.syphilis  are  very  frequent  although  not  constant:  when  they  occur 
they  are  very  often  of  the  kind  to  be  now  described,  Imt  they  are 
not  invariably  so.  If,  therefore,  we  give  the  name  "syphilis  of  the 
placenta  "  to  these  morbid  changes,  it  must  be  with  the  reservation 
that,  while  they  are  highly  suggestive  of  syphilitic  infection,  they 
are  not  absolutely  jiathognomonic  thereof.  The  pathology  of  the 
syphilitic  placenta  has  been  carefully  investigated  by  a  consider- 
able numlier  of  workers,  including  E.  Friinkel  {Areh.  f.  Gi/naeh:, 
V.  1,  1873);  C.  Hennig  (Ibid.,  'vi.  Ul,  1873-4):  K  Hervieux 
Arch,  de  tocoL,  vi.  513,  1879);  G.  B.  Ercolani  (Bull.  d.  sc.  med.  di 
Bologna,  6  s.,  xi.  217,  1883);  E.  Zilles  (Mittli.  a.  d.  rjeburtsh.-gynak. 
Klin.,  zu  Tiibimj.,  i.  Hft.  2,  p.  1,  1884);  A.  Gascard  (Thhc,  Paris, 
1885) ;  M.  Pediciui  (Progresso  med.,  Naples,  i.  67,  etc.,  1887) :  Thiel 
(Dinmi.,  Wtirzburg,  1889);  Piosinski  (Dis.'iert.,  Koni-sber--,  1889); 
Vt.  E.  d'Aulnay  (Arch,  de  tocoL,  xxi.  910,  1894);  Eckardt  (Verhandl. 
d.  dcutsch.  Gcscllschf.  Gyniik.,  vi.  627,  1895);  Schwab  (Prcsse  mM.,  ]•. 
494,  1895);  J.  D.  Bissell  (Amer.  J.  Gyn.  and  Obst.,  xi.  147,  1897): 
Audebert  (Journ.  de  med.  de  Bordeaux,  xxviii.  82,  1898):  and  \'. 
Wallich  (Rev.  2'>rat.  d'obst.  et  de  23a;diat.,  xi.  33,  1898).  By  the  naked 
eye  the  jilacenta  is  seen  to  be  larger  than  normal  and  ]>aler  in  colour 
— it  is  of  a  pale  red  with  yellowish-white  patches.  When  handled  it 
is  to  be  noted  that  it  is  softer  than  usual  and  may  even  be  frialile. 
In  the  case  of  a  dead  syphilitic  fcetus  the  weight  of  the  ])lacenta  is 
to  that  of  the  body  as  1  :  4,  whereas  in  the  absence  of  syphilis  it  is  as 
1  :  6  (C.  Euge,  Ztschr.f.  Gehurtsh.  u.  Gyndl:,  i.  ."i7,  1877).  Under  the 
microscope  the  most  important  change  is  found  to  be  a  diffuse  and 
gradual  inflammation  affecting  specially  tlie  blood  vessels.  There  is 
well-marked  endarteritis  and  very  often  a  thrombus  is  to  lie  seen 
in  the  lumen  of  the  vessel  along  with  indications  of  periarteritis 
outside.  These  changes  are  specially  developed  in  the  vessels  of  the 
villi,  in  which  also  inflammatory  proliferation  is  to  be  noted  in  tlie 
sti'oma  and  in  the  ejiitlielial  covering,  so  that  there  is  considerable 
hypertrophy  of  the  villi  with  fibrous  degeneration  of  their  ti.ssues. 


PATHOLOGY   OF   FOiTAL   SYPHILIS  231 

The  quantity  of  l>lood  circulating  in  the  foetal  part  of  the  placenta  is 
thus  diminished,  and  the  organ  becomes  more  or  less  anivniic,  with 
results  to  the  fcetus  which  can  readily  lie  understood.  But  the 
maternal  part  of  the  placenta  may  also  suffer ;  here  and  there  lui'uior- 
rhages  may  be  found  in  it  showing  various  stages  of  resorption,  and 
these,  partly  by  their  effect  on  the  maternal  blood  spaces,  and  partly 
by  separating  the  placenta  from  the  uterine  wall,  tend  still  further  to 
diminish  the  circulation  passing  through  the  organ,  and  so  render 
fcetal  death,  which  is  already  probable,  almost  inevitable.  The  so- 
called  "  gummata  "  of  the  placenta  are  probably  ha?morrhagic  in  their 
origin,  or  are  due  to  fibrous  patches  which  have  become  more  or  less 
caseous ;  possibly,  however,  true  gummata  may  in  exceptional  circum- 
'stauces  be  met  with.  An  attempt  has  been  made  to  separate  into 
two  groups  the  morbid  alterations  which  are  met  with  in  the  placenta 
— in  one  group  are  placed  the  changes  in  the  villi  and  in  their 
vessels,  and  when  these  alone  are  found  it  is  supposed  that  the  disease 
has  originated  in  paternal  infection ;  in  the  other  are  the  changes  in 
the  decidual  tissues  and  the  parts  arising  from  them,  and  when  these 
alone  are  found  a  maternal  source  is  predicated — but  it  can  hardly 
be  safely  concluded  that  any  such  grouping  is  warranted  by  the  facts. 
It  has  also  been  stated  that  the  placental  pathology  differs  with  the 
date  in  pregnancy  when  the  infection  took  place — another  statement 
which  is  easily  made  but  with  difficulty  substantiated  or  disproved. 

The  umbilical  cord. — The  commonly  occurring  change  in  the 
funis  in  cases  of  fcetal  sypliilis  would  appear  to  be  a  thickening  of 
the  vessel  walls  so  great  as  almost  to  produce  obliteration,  along  with 
the  formation  of  thrombi  in  these  narrowed  vessels.  The  vascular 
changes  in  the  cord,  taken  along  with  the  morbid  alterations  in  the 
placenta,  play  no  doubt  a  very  important  part  in  diminishing  foetal 
vitality  and  leading  to  intrauterine  death.  Forming  as  they  do  the 
first  lines  of  defence,  the  placenta  and  cord  bear  the  brunt  of  the 
attack,  and  being  also  as  it  were  the  key  of  the  position,  their  failure 
to  resist  is  immediately  disastrous.  In  neofoetal  life  it  may  indeed 
be  doubted  whether  the  syphilitic  poison  very  often  reaches  the 
organism  at  all ;  it  attacks  the  decidual  membranes  and  leads  rapidly 
to  abortion  by  the  changes  produced  in  them.  Among  other  changes 
in  the  cord  in  cases  of  syphilis,  absence  of  the  jelly  of  Wharton  causing 
dissociation  of  the  vessels  has  also  been  observed  (Mace  and  Durante, 
Ann.  de  gym'c,  xliv.  221,  1895). 

The  liquor  amnii. — There  can  be  no  reasonable  doubt  that  a 
quantitative  change  in  the  amniotic  fluid  is  a  very  frequent  result 
of  foetal  syphilis.  Hydramnios  is  so  common  in  connection  with  this 
malady,  that  some  have  been  tempted  to  regard  excess  of  the  liquor 
amnii  as  pathognomonic  of  syphilis.  This  conclusion,  however,  is 
not  warranted,  indeed  it  must  be  conceded  that  hydramnios  is  very 
common  in  all  pathological  states  of  the  fwtus ;  it  is  pathognomonic 
rather  of  fcetal  disease  and  deformity  than  of  any  one  foetal  disease 
or  deformity.  At  the  same  time,  this  generalisation  does  not  in  any 
way  lessen  the  value  of  the  well-established  fact  that  hydramnios 
is  common  in  foetal  syphilis,  it  only  prevents  us  from  ascribing  too 


232  ANTKNATAL    I'ATlIOLOCiY   ANIJ    llVCilKNF, 

.threat  u  diagnostic  importance  to  it.  The  association  of  liydianinids 
with  syphiHs  does  not  aid  very  materially  in  clearing  uj)  the  vexed 
(juestion  of  the  origin  of  the  liquor  amuii;  it  does  not  even  enable  us 
to  allirm  its  maternal  or  fcetal  origin.  Apparently  there  may  be 
iiydramnios,  not  only  when  the  fo?tus  is  distinctly  .syphilitic  but  also 
when  tiie  fcetus  is  free  and  the  niotiier  alone  afiected.  It  is,  however, 
a  fair  working  hypothesis  to  regard  tlie  hydramuios  as  largely  due  to 
increased  pressure  in  the  umbilical  vein,  caused  by  lesions  in  the 
placenta,  in  the  cord  itself,  or  in  the  fcctal  liver ;  it  may  be  compared 
with  postnatal  ascites  due  to  circulatory  troubles  in  the  portal 
system,  and  it  may  even  be  regarded  as  taking  the  place  of  portal 
ascites  in  the  fcetal  economy  {v.  P.  Bar,  L'hydramnios,  These,  Paris, 
1881).  Cardiac  and  pulmonary  lesions  in  syphilitic  fretuses  may* 
also  impede  the  circulation  and  lead  to  hydranmios.  Possibly,  then, 
it  may  lie  safe  to  regard  the  presence  of  hydramuios  as  of  grave 
import  in  cases  of  syphilis,  for  the  reason  that  it  indicates  visceral 
lesions  in  the  foetal  economy  (placental,  funic,  liepatic,  pulmonary, 
or  cardiac) ;  but  it  is  wise  to  be  slow,  very  slow  to  formulate  views 
on  these  matters,  the  antenatal  pathologist  being  like  a  storm-tosstd 
mariner  with  a  continual  lee-shore  largely  unknown  to  him  but 
dangerously  near.  Meanwhile,  let  the  reader  keep  in  mind  the 
association  of  hydramuios  and  fuetal  .syphilis.  IVIuch  nuglit  be  learned 
from  carefully  made  analyses  of  the  composition  of  the  liquor  aninii 
in  cases  of  foetal  .syphilis  in  which  the  foetus  is  alive  at  birth ;  but 
alas  •  such  analyses  are  sadly  wanting.  Quantitative  alteration  in  the 
amniotic  fluid  in  this  foetal  malady  then  is  undoubted ;  qualitative 
changes  probably  almost  certainly  exist,  but  are  of  unknown  nature. 

The  liver. — Next  in  importance  to  the  changes  in  the  placenta 
must  be  ranked  those  of  the  liver,  for  the  foetus  is  largely  dependent 
upon  the  state  of  its  placental  and  hepatic  tissues.  The  occurrence 
of  birth  excludes  the  placental  factor,  and  thereafter  the  liver  shares 
with  the  lungs  the  tirst  place  in  pathogenesis  ;  in  the  uew-born  infant, 
therefore,  .syphilitic  alterations  in  the  lungs  and  liver  are  of  great 
moment.  Yet  with  regard  at  least  to  the" hepatic  alterations,  little 
or  nothing  was  known  till  1849,  when  A.  Gubler  published  his  article 
on  .syphilitic  jaundice  {Bull.  Soc.  Anal,  dc  Paris,  xxiv.  66, 1849) ;  since 
then  many  monographs  dealing  with  the  same  subject  have  appeared, 
among  which  that  by  Lucien  Hudelo  {Contrihution  a  I'l'tude  des  lesions 
dufoie  dans  la  si/philis  hMditaire,  Varis,  1890)  may  he  singled  out 
for  special  mention ;  but  Gubler  it  was  who  broke  fresh  ground  in 
this  direction — a  memorable  name  and  date  therefore — Gubler  IS.'tO. 
To  be  quite  exact  it  was  in  1847  that  Gubler  first  noted  .special 
changes  in  the  liver  of  the  sypliilitic  new-born  infant,  but  the 
publication  of  the  fact  was  in  1849.  What,  then,  are  the  changes 
met  with  in  the  foetal  liver  in  syphilis  ? 

In  the  first  place,  lest  I  by  any  cliance  omit  to  make  the  state- 
ment, tlie  liver  may  show  no  alterations  whatever,  exhibiting  only  tlie 
naked-eye  and  microscopic  cliaracters  common  to  all  new-born  infants ; 
in  other  cases  in  which  the  ftctus  has  died  in  utero,  the  organ  will 
reveal  the  aiipearances  due  to  macerative  change,  and  these  may 


1 


Plate  x 


PATHOLOGY   OF   F(ETAL  SYPHILIS  233 

entirely  obscure  any  specific  peculiarities.     This   statement  is  true 
not  only  o^  tlir-  liver  but  also  of  all  the  organs  in  foetal  syphilis. 

In  tht  second  place,  the  liver  may  be  the  seat  of  very  special 
changes,  macroscopic  and  microscopic.  To  the  liver  thus  altered  by 
syphilis  the  French  writers  have  given  the  names  "  foie  silex  "  (Hint 
liver)  and  "foie  silex  avec  grains  de  semoule"  (Hint  liver  with 
semolina  grains) ;  the  two  names  to  some  extent  indicate  two 
diH'erent  alterations,  for  the  "  flint  liver "  may  show  none  of  the 
"  semolina  grains " ;  but  it  is  common  to  find  the  two  groups  of 
lesions  combined  in  the  same  liver,  the  semolina  change  being  the 
usual  concomitant  of  the  flinty  ("  c'est  la  satellite  habituelle  de  la 
li'sion  silex,"  Hudelo).  Some  years  ago  I  obtained  from  an  lui- 
doubledly  syphilitic  fcetus  the  liver  which  is  produced  in  I'late  X., 
it  exhibits  very  clearly  the  "  semolina  grain  "  appearance.  The  flint 
liver  ("  foie  silex  ")  is  larger  and  heavier  than  normal  and  its  margins 
are  rounded ;  its  surface  is  smooth,  and  the  consistence  of  the  organ  is 
much  incrtuised  ;ind  at  the  same  time  is  elastic;  the  colour  has  been  com- 
pareil  to  that  of  tlint  (hence  the  name  "  silex  "),  and  on  ections  this 
colu'-n*''  m  is  very  evident,  along  with  a  semi -transparency  and  a  loss 
of  th<  outlines  of  the  lobules.  Sometimes  the  flint  appearance  is 
genei  1  ("foie  silex  generalise");  at  other  times  there  are  two 
eolo-  to  be  recognised,  the  flint  tint  and  a  rather  deep  b'-owuish-red 
('■  f' i'  ilex  partiel ").  Most  commonly ,  as  has  already  been  hi.ited, 
th<  ci.rious  semolinp-grain  aspect  is  found  in  association  with  the 
yello'v  fl'nt  chan-re  (Plate  X.).  When  a  section  of  the  organ  is  care- 
f^'ly  3y  imined,  it  can  be  noted  that  scattered  here  and  there  are  little 
opuXj  .  white  spots  not  unlike  grains  of  flour  or  semolina ;  many  (if 
th«-i...  e  a  diameter  not  greater  than  one  millimeter;  they  are 
coiiv  »y  arranged  in  groups  with  the  larger  ones  at  the  centre;  and 
they  are  nu  .^  numerous  and  of  greater  size  in  the  partial  form  of  the 
flint  liv.H.  Under  the  microscope  several  changes  can  be  recognised, 
which  are  doubtless  stages  in  the  process  which  results  in  the  produc- 
tion of  the  flint  liver  with  semolina  grains.  There  may  be  simply  a 
generalised  in'.ltration  with  embryonic  colls,  a  change  which  Hudelo 
(loc.  cil.)  "ound  only  in  foetuses  born  preuiuturely ;  the  infiltration  may 
be  the  result  of  diapedesis  or  of  prolifei'ation  of  connective-tissue  cells 
or  even  possibly  of  the  hepatic  cells  themselves.  In  other  cases  there 
may  exist  small  patches  of  fibrous  tissue,  which  proliably  precede  the 
difl'use  sclerotic  change  which  is  characteristic  of  the  typical  flint 
liver  of  foetal  syphilid.  This  diffuse  interstitial  sclerosis  was  called 
fibro-plastic  induration  by  Gubler,  and  infiltrating  syphiloma  by 
Wagner ;  it  may  be  generalised  or  partial  in  extent.  Some  of  the 
liver  cells  remain  unaltered,  but  many  of  them  in  the  neighbourhood 
of  the  chief  tracts  of  sclerotic  tissue  show  various  stages  of  atrophy. 
Tlie  portal  spaces  are  enlarged  on  account  of  the  presence  of  much 
fibrous  tissue  in  them;  the  bile-ducts  in  these  spaces  are  usually 
quite  unaltered,  but  the  veins  and  sometimes  the  arteries  also  show 
thickened  walls  and  a  diminished  calibre.  The  capsule  of  the  organ 
sliows  httle  change.  It  has  been  stated  that  there  are  histological 
signs  of  an  exaggeration  of  the  haematopoietic  function  of  the  liver  in 


234  ANT]'.NATAL    I'ATII()L()(;Y   AND    HYGIENE 

fcEtal  syphilis.  UiuIlt  liu'  uiici'n.sedjit'  the  scuiohiia  grains  ("miHai\- 
syphiloinata "  <>f  Wagner,  "  miliary  gumniata"  of  Virchow)  pieseut 
themselves  as  rounded  collections  (circular,  oval,  elliptical)  of  nuclei, 
varying  in  number  from  twenty  to  one  lunnlred  in  each  grain,  and 
situated  both  in  the  hepatic  lobules  and  in  the  portal  spaces.  They 
vary  in  size  from  quite  microscopical  structures  to  bodies  having  the 
diameter  of  a  portal  sjaace.  They  would  appear  to  originate  iu  the 
neighbourhood  of  the  vessels,  and  may  arise  from  diapedesis  or  from 
proliferation  of  the  enddthelium  nf  the  capillaries. 

In  the  third  place,  the  liver  in  the  syphilitic  foetus  may  occasion- 
ally show  changes  of  a  gummatous  kind  which  are  more  commonly 
associated  with  the  manifestations  of  pmstnatal  syphilis.  For  instance, 
nodular  gunnnatous  hepatitis  has,  in  a  few  cases,  been  met  with  in 
premature  foetuses :  the  viscus  is  brownish-red  or  normal  in  colour, 
slightly  increased  or  normal  in  size,  and  of  an  unaltered  consistence ; 
in  it  are  the  gummatous  nodules,  size  of  a  jiin-head  to  that  of  a  pea  or 
bean,  lying  on  the  surface  or  embedded  in  the  suljstance  of  the  organ, 
circular  or  less  regular  in  form,  greyish-white  or  yellow  in  colour, 
firm  in  consistence,  and  not  to  be  enucleated  from  the  sin-roundlug 
hepatic  tissue.  Doubtless  they  represent  a  later  stage  than  the 
miliary  syphilomata  (semolina  grains).  Under  the  microscope  they 
show  degeneration  at  the  centre,  and  sometimes  giant  cells  are  found. 
The  presence  of  recognisable  gummata  like  those  of  postnatal  syphilis 
is  very  uncommon  in  the  foetal  liver,  but  some  few  cases  have  been 
reported  {e.g.  Hervey,  Bull  Soc.  mat.  dc  Far.  (1870),  xlv.  2(jr,  1874). 

In  the  foiirth  place,  changes  which  are  not  in  any  way  distinctive 
of  syphilis  may  be  met  with  in  the  liver.     For  instance,  wa.-y  dc 
generation  of  the  hepatic  tissue  has  been  found  in  patches  and  usuar 
in  association  with  gummatous  nodules ;  liut  it  is  rare  in  the  fcetus  or 
new-born  infant. 

Such,  then,  are  the  structural  lesions  met  with  in  the  liver  of  the 
syphilitic  fcetus ;  but  it  may  be  added  that  the  capsule  may  show 
thickening  (perihepatitis),  that  the  portal  vein  and  hepatic  artery  in 
their  course  outside  the  liver  may  exhibit  hyperplastic  changes  in 
their  walls,  and  that  the  bile-ducts  may  be  obliterated.  That  the 
hepatic  changes  taken  as  a  whole  represent  for  the  fcetus  the  chancre 
of  syphilis  acquired  postnatally,  can  hardly  be  considered  as  probaiile ; 
the  early  appearance  of  gummatous  nodules  must  Itc  regarded  as  due 
to  the  factors  which  come  into  play  in  /dial  syphilis  and  which  are 
common  to  all  fcetal  maladies.  There  is  a  hypertrophic  cirrhosis 
arising  ^jrobably  in  the  neighbourhood  of  the  vessels  which  by  it  are 
compressed  and  obliterated ;  and  although  such  changes  may  not 
develop  till  late  in  postnatal  syphilis,  in  the  antenatal  malady  there 
are  circumstances  which  permit  their  jirecocious  evolution. 

T/ic  lunr/s. — It  has  been  maintained  that  pulmonary  lesions  are 
more  fre([uent  in  foetal  syphilis  than  hepatic  lesions  (I*.  Bar,  lor.  cit.), 
but  there  are  special  reasons  why  the  pulmonary  changes  are  more 
often  observed  {e.g.  greater  resistance  ottered  liy  the  lungs  to  macer- 
ative  changes,  earlier  postnatal  death  from  ])ulmonary  than  from 
hepatic    alterations,  etc.),  and    possibly    tliey   are    not    really    more 


PATHOLOGY   OF   F(KTAL   SYPHILIS  235 

connnon.  Like  the  chauges  in  the  liver  to  which  refeieiicc  has 
been  made,  they  are  no  doulit  largely  instrumental  in  leading  to 
the  production  of  hydranmios  through  obstruction  of  the  circulation. 
The  morbid  anatomy  of  the  lungs  resembles  in  many  points  that  of 
the  liver,  and  the  patliological  appeai-ances  fall  into  four  categories. 
There  may  be  (1)  a  generalised,  diffuse  gelatinous  infiltration — 
pneumonia  gelatinosa  specifica  ;  (2)  a  form  in  which  there  exist 
thickened  patches,  white  in  colour,  and  consisting  of  air  vesicles 
crowded  with  epithelial  cells  in  a  state  of  fatty  degeneration — 
pneumonia  alba  syphilitica;  (3)  a  variety  in  which  there  are 
scattered  miliary  syphiloniata  (gummatous  growths)  with  signs  of 
interstitial  pneumonia  in  their  neighljourhood ;  and  (4)  clearly 
marked  interstitial  fibroid  pneumonia  due  to  hyperplasia  of  the 
liulnionary  connective-tissue — pneumonia  interstitialis  fibrosa  chronica 
congenita.  Much  remains  to  be  done  to  clear  up  the  pathology  of  the 
pulinonary  changes  in  fostal  syphilis  and  to  differentiate  between 
the  syphilitic  lesions  and  those  caused  by  e.g.  foetal  tubercle  and 
foetal  or  intranatal  sepsis. 

The  heart,  blood  resscls,  and  blood. — Changes  in  the  heart  have 
not  been  often  noted,  but  miliary  syphiloniata  and  rarely  gummata 
may  be  met  with  in  its  substance.  The  vessels,  as  will  douljtless 
have  been  ah-eady  gathered,  show,  as  a  rule,  widespread  and  almost 
constant  alterations,  consisting  for  the  most  part  in  endarteritis  and 
periarteritis  with  resulting  diminution  in  calibre.  According  to 
Helmut  Scharfe  (Hegar's  Beifr.  z.  Geburtsh.  u.  Gynael:,  iii.  368,  1900), 
the  antenatal  death  of  the  syphilitic  fcetus  is  often  due  to  narrowing 
of  the  ductus  arteriosus  through  changes  of  the  above  kind  ("  durch 
kolossale  Intimawucherung  ").  Bar  and  Tissier  {Ann.  dc  dermal,  et 
syph.,  3  s.,  vi.  1156, 1895)  also  deal  with  this  generalised  periarteritis  of 
foetal  syphilis.  Observations  on  the  blood  of  the  syphilitic  foetus  are 
sadly  lacking,  even  in  the  case  of  the  new-born  infant  they  are  few  : 
but  it  seems  reasonable  to  expect  that  some  changes  are  present  in 
both  the  fluid  and  corpuscular  elements  of  the  blood.  After  birth,  at 
any  rate,  a  pseudo-leukciemic  an;emia  has  been  described  ;  and  F.  Cima 
{Pediatria,  vi.  No.  12,  1898)  found  marked  diminution  in  the  amount 
of  hivmoglobin,  some  poikilocytosis  of  the  red  cells,  but  no  leuco- 
cytosis  other  than  that  commonly  present  during  the  first  weeks  of  life. 
There  is  a  fruitful  field  for  investigation  in  the  examination  of  blood 
from  the  umbilical  cord  in  the  case  of  syphilitic  foetuses ;  information 
is  also  lacking  as  to  the  value  of  the  Justus  blood-test  in  the  new-born, 
and  the  bacillus  of  syphilis  (when  isolated)  will  have  to  be  carefully 
looked  for  in  the  blood  of  the  cord  and  placenta. 

The  thymus. — Morliid  alterations  in  the  thymus  gland  have  long 
lieen  descriljed  in  connection  with  foetal  syphilis,  and  it  has  been 
customary  to  regard  them  as  of  the  nature  of  small  abscesses  or 
degenerated  patches  of  syphiloniata;  but  there  is  some  reason  to 
look  upon  them  as  cystic  formations  in  developmental  epithelial  and 
glandular  relics  emliedded  in  the  thymus  (Otto  Eberle,  Uebcr  eongcnitale 
Lxtes  der  Thymus.  Diss.,  Ziirich,  1894).  Their  precise  pathological 
significance  and  relation  to  syphilis  are  unsettled.     The  gland  may 


236  ANTENATAL    PATHOLOGY   AND   HYGIENE 

he  uoriuiil  ill  size  and  weii^ht ;  it  may  also  exliibit  induration 
(E.  Schlesinger,  Arch.f.  Kiiidcrhll:,  xxvi.  205,  1899.). 

The  suprarenal  capsules. — The  adrenals  are  usually  somewhat 
enlarged,  and  histologically  they  may  exhibit  an  infiltration  with 
embryonic  cells,  or  a  hyperplasia  of  the  connective-tissue  witli  atrophy 
of  the  cells  peculiar  to  the  organs.  In  some  cases  hyjjertrophy  of  the 
epitiielial  cells  has  been  noted,  constituting  what  may  be  looked  ujion 
as  small  adenomata;  ha-morrliages  are  not  uncommon,  Init  are  proliably 
in  no  way  characteristic  of  syphilis.  (L.  Petit,  Lesions  ties  capsules 
stirrcnales  dans  la  syphilis  eowjenitcde.  These,  Lyun,  1900-190L) 

The  spleen. — This  organ  is  practically  always  enlarged  in  the 
syphilitic  foetus  (E.  Keckev, Dcutsches  Arch.f.  klin.  Med.,\y.\.  1, 1898), 
There  is  a  spilenitis  ^Mc</crt,  although  Bar  {loe.  eit.)  did  not  meet  with  il 
in  the  cases  examined  Iiy  him,  and  regarded  the  hypertrf>phy  as  purely 
the  result  of  circulatory  disturbances  in  the  portal  system.  There  is  a 
small-celled  iutiltration  of  the  large  and  medium-sized  l>lood  vessels. 

Tlie  pancreas. — In  the  pancreas,  lesions  similar  to  those  in  the  liver 
may  be  encountered;  there  is  a  small-celled  iutiltration,  with  fil)rous 
tissue  formation,  induration,  and  consequent  hypertrophy  of  the  organ. 
The  vascular  walls  are  thickened,  while  the  proper  epithelial  tissue  of 
the  gland  is  in  a  more  or  less  atrophic  state.    The  vveight  is  increased. 

The  kifbici/s. — The  kidneys,  like  the  other  organs  in  the  syjihilitir 
foetus,  show  an  increase  in  weight  so  that  they  become  one  eighth- 
sixth  instead  of  about  one  hundred  and  twentv-third  of  the  total  liodv 
weight  (Hecker,  Jahrb.  f.  Kinderhlk.,  n.  F.,"  i.  375,  1900).  Of  late 
their  histology  has  been  accurately  studied  Ijy  Hecker  {loe.  eit.),  and  in 
a  very  complete  fashion  liy  J.  J.  Karvouen  (Die  Nicrcnsyphilis,  Akad. 
Abhandl.,  Helsingfors,  1898).  The  latter  writer  states  that  renal 
lesions  are  rarely  met  with  in  the  syphilitic  fcetus,  possibly  l)ecause  it 
perishes  before  they  have  time  to  develop :  but  the  former  found 
them  in  every  one  of  ten  dead-born  syphilitic  fietuses.  At  first  there 
is  a  small-celled  infiltration  of  the  small  vessels  of  the  cortex  and 
sometimes  of  the  larger  vessels  of  the  medulla ;  frequently  also  tliere 
co-exist  a  proliferation  of  the  interstitial  connective-tissue  and  an 
endo-  and  peri-arteritis  of  the  small  vessels  of  the  cortex.  In  full- 
time  fcetuses  the  vascular  and  perivascular  infiltration  is  less  marked, 
but  degeneration,  more  or  less  marked,  of  the  epithelium  is  quite 
recognisable.  It  is  rare  to  find  parenchymatous  lesions  unless  the 
fictus  has  survived  birth.  A  most  interesting  histological  pecvdiarity 
— the  presence  in  the  kidney  substance  of  fcctal  epithelial  relics — is 
discussed  at  length  l)y  Carl  Hochsinger  (Studicn  nher  die  hcreditdei 
Si/2}hilis,  p.  415,  1898);  it  was  pointed  out  by  Stroebe  some  ten  years 
ago  {Cenfrlbl.f.  all;/.  Path.  u.  path.  Anat.,  ii.  1009,  1891). 

The  intestines  and  peritoneum. — Intestinal  lesions  in  fo'tal  syphilis 
{e.g.  atrophy  of  small  intestine)  have  not  been  often  describeil.  but  fur 
many  years  antenatal  j)eritonitis  has  lieen  regarded  as  sypliilitic  i)i 
nature.  As  long  ago  as  1838,  J.  Y.  Simpson  pointed  out  this  associa- 
tion of  ])eritonitis  and  sy])liilis,  and  stated  that  "  a  great  proportion  nf 
those  children  that  die  in  the  latter  months  of  pregnancy  may  yet 
be  shown  to  have  perislied  under  attacks  of  peritoneal  inliannnation 


\ 


PATHOLOCiY   OF   I-XETAL   SYPHILIS  237 

(ObsM)-ic  IJ'orls.  vol.  ii.  p.  ]52,  185G).  Xn  doubt  peritonitis,  oI'Ilmi 
accompanied  by  eftiisiou  (fcetal  ascites),  is  fre(piently  met  with  in 
syphilis;  but  it  is  not,  of  course,  pathognomonic,  and  it  may  arise 
from  quite  other  causes.  The  presence  of  fluid  in  the  peritoneal 
cavity,  in  the  absence  of  other  changes,  cannot  be  regarded  as  peri- 
touitis;  there  must  be  not  only  serum  but  also  flakes  of  lymph,  and 
the  intestinal  coils  must  lie  more  or  less  adherent  to  each  other  and  to 
the  abdominal  viscera.  In  the  case  of  syphilitic  fcetuses  that  have 
succumbed  in  utero  and  undergone  a  certain  degree  of  maceration,  the 
presence  or  absence  of  peritonitis  is  most  difficult  to  determine.  The 
other  serous  cavities  may  likewise  contain  fluid  effusions  (e.g.  hydro- 
cephalus, hydropericardium,  and  hj-drothorax). 

The  testicles. — The  changes  in  the  testicles  resemble  those  in  the 
other  viscera.  There  is  a  small-celled  infiltration  of  the  connective- 
tissue  in  the  neighbourhood  of  the  vessels,  and  at  a  later  stage  the 
special  tissue  of  the  organ  becomes  affected  by  the  surrounding  sclerosis, 
and  atrophy  of  the  seminiferous  tubules  follows. 

The  nervous  system. — That  the  nervous  tissues  suffer  in  foeta! 
syphilis  cannot  he  doubted  ;  but  the  morbid  alterations  that  are 
found  in  them  are  better  described  as  malformations  or  dystrophies 
than  as  diseases.  The  reason  is  probably  to  be  found  in  the  fact  that 
the  brain  is,  even  at  the  end  of  the  foetal  period,  still  in  a  state  of 
incomplete  development,  and  that  peccant  matters  acting  ujMn  it  will 
therefore  determine  anomalies  of  construction  rather  than  diseases  in 
the  strict  sense  of  the  word.  To  these  dystrophic  states  I  shall 
return  immediately.  The  spinal  cord,  however,  which  is  almost  fully 
developed  at  birth,  may  show  signs  of  fa?tal  syphilis ;  these  take  the 
form  of  diffuse  meningo-myelitis  with  an  infiltration  of  small  cells, 
and  lead  to  a  pathological  state  resend^ling  in  nature  the  interstitial 
hepatitis  which  has  been  described  above  (Gilles  de  la  Tourette,  A'^our. 
iconor/.  de  la  Salpetriere,  ix.  80,  1896). 

The  skeleton. — The  osseous  sy.steni,  like  the  nervous,  is  in  a  state 
of  development  even  at  the  time  of  birth,  and  is  therefore  like  it 
also  the  seat  of  malformations ;  but  in  addition  to  these,  to  which 
reference  will  again  be  made,  it  shows  frequently  some  ^'erv  charac- 
teristic changes  which  fall  into  the  category  of  diseases.  To  these 
changes  the  name  of  Wee/ner's  sign  has  been  given,  for  G.  Wegner 
was  the  first  to  draw  special  attention  to  their  diagnostic  importance 
(Arch.  f.  path.  Anat.,  1.  305,  1870).  At  the  dividing  line  between 
the  diaphysis  and  the  epiphysis  of  a  long  bone  such  as  the  tibia,  there 
is  a  jagged,  broad  yellow  line  separating  the  bone  of  the  shaft  from 
the  cartilage  of  the  extremity.  In  non-syphilitic  foetuses  there  is 
no  such  line,  there  being  simply  a  sharply  defined  boundary  where 
cartilage  ceases  and  osseous  tissue  begins.  To  ascertain  the  presence 
of  this  yellow  line  of  foetal  syphilis,  the  head  of  one  of  the  long  bones 
(e.g.  of  the  femur)  is  cut  down  upon,  and,  having  been  exposed,  is 
split  vertically  by  means  of  a  strong  cartilage  knife.  The  condition 
may  be  found  in  various  stages  or  degrees  from  a  slight  thickening 
of  the  normal  thin  white  dividing  line  to  the  marked,  broad,  irregular 
yellow  tract  described  above.     In  the  major  degrees   there  may  be 


2:'.8  ANTENATAL    I'ATHOLOC;^'    AND    HYC.IF.NK 

also  some  ihickeuiiii,'  of  Ihe  pciinsleum  aiul  peiicliuiiilriuni.  Tlie 
process  which  leails  lo  these  (■han<j;es  lias  lieeii  called  syphilitic  osteo- 
chondritis ;  the  iiewly-l'ormed  cells  between  the  cartilage  and  the 
hone  are  of  low  vitality,  and  undergo  degenerative  changes  of  a 
fatty  or  caseous  kind.  During  or  after  birth,  separation  of  ihe 
head  from  the  shaft  of  a  long  bone  may  take  place ;  possibly 
this  may  also  occur  in  utero  with  subse([uent  healing  of  the 
separation  and  the  formation  of  much  callus  (osteojjhyte).  Other 
conditions  of  the  bones  (both  long  and  Hat)  have  been  described 
in  connection  with  syphilis ;  and  J.  Parrot  {La  syphHU  ht'rMilairc 
ct  Ic  rachitis,  Paris,  1886)  has  gone  so  far  as  to  state  that  racliitic 
changes  are  always  the  results  of  the  action  of  the  syphilitic 
virus,  a  statement,  however,  wliicli  lias  not  been  cunfiruu'd  by 
others. 

Such  are  the  visceral  and  skeletal  changes  which  may  lie  met 
with  in  the  syphilitic  fcctus ;  it  cannot  be  athrmed  that  any  one  of 
them  must  Ije  present  in  order  to  prove  the  e.xistence  of  fu'tal 
syphilis,  but  the  presence  of  several  of  them  in  condiinatiou  may  be 
held  to  fulfil  all  the  requirements  of  even  an  e.xacting  diagnosis. 
It  may  even  be  found  that  the  presence  of  the  peculiar  osteo- 
chondritis of  the  long  bones  is  sutticient  in  itself  to  constitute  a  post- 
mortem diagnosis  of  the  malady,  but  it  is  not  invariably  present. 
T!ie  association  of  increase  in  weight  of  the  viscera,  along  with  the 
bone  changes  and  those  in  the  liver,  kidneys,  lungs,  and  tliynuis, 
ought  to  enable  the  pathologist  to  be  certain  that  he  is  dealing  with 
foatal  syphilis  ;  and  there  need  to  be  no  doubt  at  all  if  there  exist 
also  placental  changes  and  hydramnios. 

In  order,  however,  to  complete  our  survey  of  the  morliid  anatomy 
of  foetal  syphilis,  we  must  pass  in  review  the  alterations  met  with 
in  the  skin  and  subcutaneous  tissue  at  the  moment  of  birth. 

The  skin. — The  .syphilitic  fcrtus  may  come  into  the  world  with 
the  bulke  of  pemphigus  in  full  eruption ;  the  characters  of  this 
syphilitic  form  of  pemphigus  have  been  already  described,  and  need 
not  be  dealt  with  further,  but  it  may  be  remarked  in  passing,  that 
this  cutaneous  manifestation  of  the  disease  is  {when  it  hapiKns  to  he 
present)  of  very  great  diagnostic  value.  Besides  pemphigus,  however, 
the  skin  may  show  an  alteration  to  which  the  name  of  ichthyosis 
has  sometimes  been  applied.  Let  it  be  at  once  noted  that  this  con- 
dition is  not  the  same  as  that  called  fietal  ichthyosis:  that  is  a 
malady  which  will  be  described  as  one  of  the  tyjies  of  the  idiopathic 
diseases  of  antenatal  life ;  it  has  very  clearly  marked  characters,  and 
is  nearly  always  associated  with  an  absence  of  all  indications  of 
syphilis  in  the  parents.  The  condition  referred  to  liere,  as  occurring 
in  the  syphilitic  fn-tus,  is  more  of  the  nature  of  an  excessive  cuticular 
desquamation,  a  pseudo-ichthyosis.  It  shades  off  by  degrees  into  the 
inacerative  states  of  the  skin  fnund  in  the  sy]ihilitie  fictus  which  has 
died  in  utero.  It  must,  however,  be  borne  in  mind  that,  although  the 
.syphilitic  infant  often  dies  in  utero,  and  is  expelled  showing  all  the 
alterations  due  to  ]>ost-mortem  maceration,  yet  a  macerated  fcctus  is 
not  necessarily  a  syphilitic  fietus.     It  is  doubtful,  indeed,  whether 


DYSTROPHIES   OF   ANTENATAL  SYPHILIS  L'^O 

there  are  any  jieculiarities  about  the  inacerative  changes  in  fci'tal 
syphilis  which  will  enable  the  pathologist  to  ditterentiate  tliem  from 
the  alterations  whicli  follow  upon  intrauterine  deatli  due  to  non- 
syphilitic  causes.  If  death  have  not  preceded  birth  too  long,  it  may 
be  possible  from  the  discovery  of  the  characteristic  osseoiis,  hepatic, 
renal,  aud  pulmonary  changes,  to  state  definitely  that  here  was  a  case 
of  death  from  syphilis;  but  in  many  instances  no  such  conclusion 
can  be  safely  drawn.  Certainly  the  condition  known  as  hydrops  san- 
(jwinolcntus,  which  is  simply  well-marked  maceration,  is  not  of  neces- 
sity syphilitic.  General  tVctal  dropsy  or  general  anasarca  of  the  infant 
born  ahve  may  sometimes  be  syphilitic  in  origin,  but  assuredly  it  is 
not  always  so,  being,  in  fact,  a  symptom  of  various  morbid  states 
rather  than  itself  a  distinct  morbid  entity.  Finally,  in  describing 
the  cutaneous  manifestations  of  foetal  syphilis,  it  has  to  be  noted 
that  the  eruptions  (erythematous,  papular,  and  the  like)  which  are 
so  characteristic  of  the  malady  in  infants  are  seldom  present  at  birth, 
at  least  have  seldom  been  noticed  then ;  this  immunity  may  perhaps 
be  due  to  the  intrauterine  environment  (as  has  already  been  sug- 
gested). 

It  may  be  added  that  fissures,  ulcerations,  and  condylomata 
about  the  mouth  and  anus,  as  well  as  other  syphilitic  affections  of  the 
mucous  membranes,  would  appear  to  be  rarely  observed  in  the 
syphilitic  infant  at  the  moment  of  birth. 

It  must  be  borne  in  mind,  that  of  the  pathological  conditions 
which  have  been  described,  many  are  rarely  met  with,  while  some- 
times hardly  any  of  them  will  be  markedly  present.  On  the  other 
hand,  the  pathologist  occasionally,  although  perhaps  very  rarely, 
meets  with  a  case  in  which  nearly  all  of  them  can  be  recognised  in 
the  same  fcetus.  Thus  G.  Mathewsou  {Prag.  vied.  Wchnschr.,  xx. 
llo,  1895)  has  described  a  seven-months'  foetus  in  which  there  were 
the  following  morbid  states :  pemphigus ;  encephalitis ;  gummata  of 
the  meninges,  thymus,  lungs,  myocardium,  liver,  kidneys,  and  right 
femur ;  hypertroi^hy  of  the  spleen ;  osteo-chondritis  in  the  long 
bones ;  multiple  ecchymoses ;  hydrothorax  and  ascites ;  and  placental 
infarcts. 


Dystrophies  of  Antenatal  Syphilis. 

Now,  in  order  to  complete  the  picture  of  the  morbid  anatomy  of 
foetal  syphilis,  it  is  necessary  to  mention  what  ha^'e  been  called  the 
dystrophics.  A  reference  to  what  has  been  written  on  page  185  con- 
ceruing  the  embryonic  factor  in  foetal  pathology,  will  enable  the 
reader  better  to  understand  the  relation  of  the  dystrophies  to  the 
ordinary  pathological  changes  of  antenatal  syphilis.  It  has  already 
been  pointed  out  in  the  description  of  foetal  typhoid  and  fcetal 
tubercle  (pp.  201,  214),  that  sometimes  the  infant  of  a  woman 
suffering  from  one  of  these  maladies  showed  not  the  ordinary  mani- 
festations of  typhoid  or  tubercle,  but  slight  anomalies  of  structure,  or 
actual  malformations,  or  abnormal  tissue  reactions  leading  to  early 
postnatal  debility  and  death.     In  the  case  of  tubercle,  I  called  these 


240  ANTFAATAI,    I'AIIlOI.OCiV    AND    HYGIENE 

the  nou-liiln;rcul;u-  manifestations  of  antenatal  tuliercle;  similarly  in 
the  case  of  syiihilis  they  might  be  called  the  uon-syphilitic  mani- 
festations of  antenatal  syphilis.  At  the  same  time  this  nomenclature, 
although  in  one  sense  convenient,  is  probalily  the  ei;]iression  of  an 
erroneous  conception  of  the  real  nature  of  the  malformations  and 
anomalous  tissue  reactions  which  are  met  with  in  the  otlspring  of 
tubercular  or  syphilitic  parents.  Perhaps  it  is  best  (in  the  ease 
of  foetal  syphilis,  at  any  rate)  to  retain  the  name  "dystrophies." 
What  then  are  these  dystrophies  which  are  found  sometimes  in  the 
foetuses  of  syphilitic  parents,  and  what  is  the  probable  explanation 
of  their  mode  of  origin  ? 

Eduiond  Fournier  has  written  a  large  work  (Stu/matcs  dysiroph- 
iqucs  do  I'/u'n'do-si/philis,  Paris,  18f)8),  into  which  he  has  condensed 
most  of  the  information  which  has  been  accumulated  regarding 
foetal  dystrophic  states.  Fournier  points  out  that  syphilis  has  two 
sorts  of  hereditary  consequences,  namely,  (1)  the  transmission  of 
syphilis  itself,  in  nature  and  in  substance,  from  the  ascendant  to 
the  descendant :  and  (2)  the  transmission  of  various  pathological 
characters,  having  nothing  syphilic  in  them,  and  consisting  either  in 
innate  inferiorities  of  constitution,  of  temperament,  or  of  vital  resist- 
ance, or  in  arrests  and  imperfections,  as  shown  in  deviations  of 
physical  and  intellectual  development,  in  organic  malfornuitions,  and 
even  in  monstrosities.  The  first  of  these  groups  of  pathological 
conserpiences  constitutes  syphilitic  heredity  proper,  and  the  second 
may  be  called  the  dystrophic,  parasyphilitic,  or  toxinic  results  of 
syphilitic  heredity.  I  may  interpolate  here  my  objection  to  the  use 
of  the  woi-d  "  heredity  "  in  the  above  senses ;  to  my  mind,  it  is  less 
likely  to  confuse,  if  one  speaks  of  two  sets  of  consequences  of  the 
transmission  of  the  syphilitic  poison  from  parents  to  offspring:  (1) 
the  ordinary  pathological  manifestations  of  syphilis,  e.(/.  small-celled 
infiltration,  thickening  of  vessel-walls,  syphilomata ;  and  (2)  the 
syphilitic  dystrophies  or  anomalies  of  structure  and  of  tissue  re- 
action, which  difi'er  from  the  patently  syphilitic  manifestations  of  the 
first  group. 

It  is  impossible  to  give  in  detail  the  description  of  the  various 
dystrophies  that  Fournier  has  found  in  the  progeny  of  syphilitics ; 
but  I  have  cast  some  of  them  into  the  following  tabular  statement : — 

A.  General  Dystrophies — 

1.  Simian  or  senile  pliy.'^iognomy. 

2.  Infantilism  and  "  dwavf-fa'tus." 

3.  Rachitis  (?). 

4.  Osteogenic  exostoses. 

B.  Parti. \i.  Dystrophies — 

1.  Cranial  dystrophies,  including  cranial  malformations,  asym- 

metry, synostoses,  microcc]ihalv,  and  hydrocephaly. 

2.  Dental  and  maxillary  d3'strophies,  including  microdontisiii, 

absence  of  certain  teeth,  dental  vulnerability,  and  iiial- 
formatious  of  the  jaws. 


DYSTROPHIES   OF   ANTENATAL   SYPHILIS  241 

3.  Hare-lip,  cleft  palate,  and  occlusion  of  nares. 

4.  (Jcular  and  aural  dystrophies,  including  colobonia,  strabismus, 

and  various  malformations  of  the  external  ear. 

5.  Spinal  malformations,  e.g.  spina  bifida  and  scoliosis. 

6.  Dystrophies  of  the  limbs,  including  partial  giantism,  micro- 

niely,  Polydactyly,  syndactyly',  ectrodactyly,  ectromely, 
congenital  dislocation  of  the  hip,  and  club-foot. 

7.  Cerebral  dystrophies  and  anomalies  of  the  spinal  cord,  deaf- 

mutism. 

8.  Cardiac  and  vascular    anomalies,  congenital    cyanosis,  Kay- 

naud's  disease. 

9.  Anomalies  of  the  digestive  sj'stem,  e.g.  anal  iniiierforation, 

hernia. 

10.  Genito-urinary   malformations,    e.g.    vesical    and    testicular 

ectopia,    epispadias,    cryptorchidy,    uterine   and   vulvar 
anomalies. 

11.  Cutaneous     dystrophies,     including     ichthyosis,      alopecia, 

nrevi,  scleroderma,  and  dermoid  cysts. 

12.  Anomalies  of  the   fcetal   annexa,   e.g.  tightness   of  amnion, 

hydatid  mole. 

13.  Monstrosities,     e.g.    exomphalos,     anencephalus,     pseuden- 

cephaly,  meningocele,  etc.  etc. 

C.  Dystrophies  of  Intellectual  Development — 

1.  Eetarded  development,  e.g.  backwardness. 

2.  Arrested  development,  e.g.  idiocy. 

D.  Dystrophies  op  Predisposition — 

1.  Hsemorrhagic    diathesis,  general  or  liieal    obesity,  and    par- 

o.xysmal  hsemoglobinuria. 

2.  Tubercle. 

3.  Nervous  diseases,  e.g.  convulsions,  Little's  disease,  epilepsy, 

hysteria,  neurasthenia,  etc. 

Truly  the  dystrophies  of  syphilis,  as  enumeiated  by  Fournier,  con- 
stitute a  lengthy  and  imposing  list.  Of  course,  it  is  not  claimed 
that  in  all  the  individual  cases  narrated  in  Fournier's  work  {oji. 
cit),  syphilis  was  the  cause  of  the  dystrophy ;  in  some  instances 
the  malformation  and  the  syphilitic  taint  were  no  doubt  accidentally 
associated;  but  the  important  conclusion  remains  that  we  cannot 
regard  the  co-existence  of  anomalies  of  structure  {and  more  especially  of 
malformations)  and  a  syphilitic  parentage  as  accidental.  In  isolated 
cases  the  association  may  be  a  coincidence,  but  the  coincidences  are 
numerous  enough  to  enable  us  to  affirm  a  relation  of  cause  and  effect. 
Xumerous  as  are  the  recorded  dystrophic  states  which  have  been  found 
in  syphilitic  offspring,  I  would  add  to  their  number  the  instances 
of  the  presence  of  embryonic  relics  in  the  thymus  gland  and  kidneys, 
to  which  reference  has  already  been  made. 

It  may  be  insinuated   that  the  very  variety  of  the  dystrophies 
is   proof   that  they  cannot   be  of  syphilitic   origin;    but  it  may  be 
said  in  answer  that  the  polymorphism  of  syphilitic  manifestations 
i6 


242  ANTKXATAI.    PA  11  lOI.OdV    AM)    HYGIENK 

('-.(/.  tlie  cut;uK'inis  iilil'ctioiis  of  infantile  KVphilis)  is  pruvt'i-hial.  A 
niiiie  inijiortanl  oljjeclion  is  fimnd  in  the  remark  that  many  of  tiie 
dystrojiliic  states  named  in  connection  with  antenatal  syphilis  may  be 
found  also  in  the  progeny  of  tuljercular  and  alcoholic  parents.  That 
is  quite  true;  but,  as  will  be  shown  immediately,  when  the  probable 
explanation  of  these  parasyphilitic  signs  is  considered,  this  is  just 
what  might  be  expected. 

If  the  reader  will  now  turn  back  to  pages  7-12  and  185,  he  will 
be  the  better  able  to  understand  the  explanation  of  the  dystro])liies 
which  is  here  set  forth.  He  will  Hnd  it  pointed  out  in  these  passages 
that  before  the  fa>tal  period  of  antenatal  life  there  is  a  formative  or 
embryonic  epoch  dviring  which  the  organs  are  being  constructed.  It 
may  be  taken  as  a  good  working  hypothesis  that  morbid  agents,  such 
as  the  virus  of  syphilis,  acting  upon  the  organism  in  this  organ- 
forming  period,  will  produce  results  of  the  nature  of  malformations 
{i.e.  malforming  of  organs).  It  may  be  supposed,  therefore,  that  some 
of  the  dystrophies  are  due  to  the  action  of  the  syphilitic  poison  or 
toxin  upon  the  organism  in  its  embryonic  state,  i.e.  in  the  first  six 
weeks  of  pregnancy.  The  dystrophies  so  produced  will  be  of  a  grave 
character,  e.g.  monstrosities,  and  such  malformations  as  hare-li]>, 
exstrophy  of  the  bladder,  and  anal  imperf oration ;  for  it  is  ^ery 
improbaljle  that  any  morljid  agent  could  produce  these  changes  after 
the  embryonic  period  is  past.  But,  further,  it  will  be  remembered 
that  I  pointed  out  in  my  corrected  scheme  of  antenatal  life  {vide 
p.  10),  that  all  organ-formation  is  not  finished  in  the  embryonic 
period;  some  embryonic  developments  occur  during  the  fo'tal  period, 
among  which  may  be  mentioned  the  complete  formation  of  the  .skin 
and  its  appendages,  of  the  genital  organs,  of  the  limbs,  of  the  eye  and 
ear,  of  the  face,  of  the  brain,  and  of  the  skeleton  {ride  "  Scheme  of 
Development  of  Organs,"  on  p.  97).  Let  us  suppose,  then,  that  the 
morbid  agent  {e.g.  syphilis)  continues  to  act  tipon  the  organism  in  its 
fcetal  epoch  of  intrauterine  life,  it  will  interfere  with  the  yiroper 
formation  of  the  organs  which  are  now  in  the  formative  p.hase,  lho.se, 
namely,  that  have  been  mentioned  above.  So  here  again  a  series  of 
dystrophies  will  arise  of  a  less  grave  type,  and  afiecting  the  skeleton, 
the  limbs,  the  face,  and  sense  organs,  the  skin,  the  genitals,  and 
the  brain.  If  the  reader  will  glance  at  Fournier's  list  of  dystrojihies, 
he  will  find  just  these  very  organs  holding  a  foremost  place.  But  it 
will  no  doubt  have  been  already  noted  that  some  of  the  dystrophies 
therein  enumerated  are  the  dental  anomalies  and  infantilism,  that  is  , 
to  say,  malformations  which  cannot  well  be  supposed  to  have  originated  ; 
in  the  fcetal  period.  But,  as  I  pointed  out  in  the  scheme  already ; 
referred  to  {vide  p.  10),  some  small  amount  of  organ-formation  takes 
place  in  postnatal  \Ue,  e.g.  the  teeth,  and  it  is  also  after  birth  that; 
there  is  a  continuance  of  the  growth  of  all  the  tissues  and  organ.=. 
It  must,  tlieu,  be  seen  that  dystrophies  d\ie  to  the  continued  (ii^.-it- 
natal)  intiuence  of  the  syphilitic  or  other  virus  will  take  the  form 
of  dental  and  growth  anomalies,  that  is,  they  will  find  expression  in| 
the  sjiecial  pathological  possibilities  of  the  epoch.  It  thus  comes 
about  that  one  morbid  cau.se  can  yet  produce  such  diverse  anomalies 


PATHOGENESIS   OF   FCETAL  SYPHILIS  243 

iiuil  lualt'ormatioiis  as  are  euuuiei'ated  in  Founiiev's  list  nf  ilystrophies. 
The  dystrophies,  let  it  be  also  uoted,  luay  occur  in  combination  with 
the  ordinary  pathological  changes  of  syphilis,  or  (rarely  perhaps) 
alone.  The  ordinary  manifestations  of  syphilis,  I  take  it,  are  those 
due  to  the  action  of  the  virus  upon  the  organs  or  tissues  whose 
development  is  so  to  say  complete,  which  have  in  other  words  passed 
out  of  the  embryonic  stage  and  entered  the  epoch  of  growth  and 
functional  activity.  It  is  quite  possible,  therefore,  that  l)oth  the 
dystrophies  and  the  ordinary  morbid  changes  of  syphilis  may  be  met 
with  in  the  same  infant  at  birth ;  in  syphilis  acquired  late  in  preg- 
nancy, the  grave  dystrophies  are  practicalh'  certain  to  be  absent,  and 
indeed  nothing  may  then  be  found  save  the  ordinary  results  or 
syphilitic  lesions  in  the  strict  sense  of  the  word.  To  sum  up,  there- 
fore, it  may  Ije  said  that  the  dystrophies  are  the  result  of  the  action 
of  the  syphilitic  poison  upon  the  organism  during  the  embryonic 
stage  of  antenatal  life,  or  upon  such  of  its  organs  and  tissues  which 
during  the  foetal  (and  even  the .  postnatal)  period  are  still  in  the 
embryonic  or  formative  condition. 

An  interesting  question  may  be  referred  to  briefly  at  this  stage : 
How  far  do  other  morbid  agents  (apart  from  syphilis)  produce 
dystrophies  ?  There  is  good  reason  to  believe  that  tubercle  often 
does  (vide  pp.  214—216),  so  also  does  alcohol;  and  there  is  some 
evidence  that  sepsis  and  the  enteric  poison  may  occasionally  produce 
dystrophic  effects.  It  may  ultimately  be  found  that  all  the  agents 
which  produce  disease  in  formed  organs  and  tissiies  produce  mal- 
formations or  dystrophies  in  developiug  or  forming  structures. 

Another  question  remains  to  be  answered  under  this  heading :  Can 
the  dystrophies  of  syphilis  be  regarded  as  in  any  way  special  and  to  be 
distinguished  from  (let  us  say)  those  of  alcohol  or  tubercle  ?  Fournier 
is  of  opinion  that  to  some  extent  they  can  be,  and  refers  especially  to 
infantQism  (a  group  of  dystrophies),  cranio-facial  malformations,  and 
dental  anomalies,  as  characteristic  (especially  when  all  co-existing  in 
one  subject)  of  the  dystrophies  of  syphilis ;  but  it  may  be  doubted 
whether  there  is  sufficient  evidence  to  warrant  this  conclusion.  I 
believe  that  it  can  hardly  be  affirmed  that  any  of  the  dystrophies 
are  peculiar  to  any  one  of  the  morbid  causes  (syphilis,  tubercle, 
alcohol) ;  indeed,  the  dystrophies  may  be  met  with  apart  fi'oni  any  of 
these  states.  Possibly  the  dystrophies  of  syphilis  may  be  special,  in 
the  sense  that  they  are  very  numerous  and  very  various.  The  whole 
question  of  the  nature  of  malformations  and  monstrosities  will,  of 
course,  receive  full  consideration  in  a  future  volume  dealing  with 
the  pathology  of  the  embryo  and  germ.  The  reference  to  it  here  is 
due  to  that  projection  of  embryonic  into  fcetal  life  which  I  have 
already  several  times  alluded  to  {vide  pp.  9,  12,  185). 

Pathogenesis. 

I  have  now  to  deal  with  a  very  complex  and  difficult  part  of  the 
subject  of  fffital  syphilis,  namely,  its  pathogenesis.  In  considering  the 
mode  of  origin  and  of  transmission  of  this  malady,  it  is,  in  the  present 


244  ANTKNATAI.   PATHOI.OCY    AND    HYGIENK 

state  of  our  knowledge,  impossible  to  seijurate  fa'tal  from  embryonic 
and  germinal  syphilis.  We  must  of  necessity  to  some  extent  consider 
them  togetlier ;  and  we  are  thus  led  into  a  veritable  maze  of  theories, 
views,  opinions,  and  hypotheses,  with  here  and  there  a  stray  fact  or 
pseudo-fact  turning  out  on  closer  inspection  to  be  far  otherwise. 
We  must  abbreviate  as  far  as  is  possible  this  wandering  about 
among  innumerable  theories  and  apparent  facts. 

With  regard,  in  the  first  place,  to  the  nature  of  the  cansal  wjent  in 
syphilis,  it  may  be  taken  as  a  working  hypothesis  and  as  a  probable 
conclusion  that  it  is  niicrobic  or  parasitic.  It  is  more  than  likely 
that  before  long  it  will  be  found  lliat  sy]ihilis  will  take  its  place 
alongside  of  tubercle,  typhoid  fever,  and  malaria  as  due  to  the  action 
of  a  microbe  or  parasitic  organism  upon  the  tissues  of  the  liody.  As 
long  ago  as  1841,  Vanoye  pulilished  a  note  u])on  an  animalcule  found 
in  syphilitic  pus  {Ann.  Soc.  d.  sc.  nat.  de  Bruges,  ii.  39,  1841);  and  in 
1868,  J.  H.  Salisbury  gave  "a  description  of  two  new  algoid  vegeta- 
tions, one  of  which  appears  to  be  the  specific  cause  of  sypliilis  and 
the  other  of  gonorrhrea"  {Amer.  Jmirn.  Med.  Sc,  n.  s.,  Iv.  17,  1868); 
but  it  was  not  till  1880  that  the  search  for  the  causal  organism  of 
syphilis  became  really  prolific  in  results.  From  that  date  (1880), 
when  Bermann  published  his  article  on  "  The  Fungus  of  Syjjhilis " 
(Arch.  Med.,  New  York,  iv.  263,  1880),  up  to  the  present  time  there 
has  been  a  steady  output  of  articles  dealing  with  the  "  bacteria," 
"  microbes,"  "  bacilli,"  "  streptococci "  and  "  micrococci "  and  "  fiuigi " 
of  syphilis.  The  subject  has  been  dealt  with  by  .such  authorities  as 
Doutrelepont,  Finger,  Kassowitz,  Hochsinger,  Lustgarten,  Doehle, 
and  Xeisser  :  and  on  several  occasions  it  has  been  declared  with  more 
or  less  confidence  that  at  last  the  causa  causans  was  found.  Eecently 
it  has  been  affirmed  with  more  than  usual  confidence  that  the  liacillus 
of  syphilis  had  lieen  isolated  by  Justin  de  Lisle  and  Jullien  {Acad, 
dc  mid.,  Paris,  3  s.,  xlvi.  p.  50,  1896) ;  it  is  descril)ed  as  poly- 
morphic (short,  threadlike,  etc.),  it  is  said  to  produce  (in  the  guinea- 
pig)  an  indurated  ulcer  with  swelling  of  the  nearest  lymphatic  glands, 
and  the  blood  of  syphilitic  ])atients  added  to  a  three  days'  nld  culture  of 
the  bacillus  causes  agglutination  of  the  latter.  For  culture  ]iurposes 
de  Lisle  and  Jullien  used  blood  plasma  separated  fi-om  the  serum, 
and  also  fluid  from  blisters,  for  they  hold  that  the  negative  lesults 
previously  obtained  were  due  to  the  presence  in  the  coagulated 
blood  of  a  bactericidal  alexin,  and  they  regard  the  above  media 
as  alexin-free.  Whether  this  polymorphic  micro-organism  be  at 
last  tlie  real  bacillus  of  syjihilis  or  not,  does  not,  from  the  pre- 
sent standpoint,  matter  very  much ;  it  is  sufficient  to  accept 
as  a  good  wurking  hypothesis  the  idea  that  sy]ihilis  is  due  to  a 
microbe. 

In  tlio  second  place,  we  have  to  consider  the  mode  of  transmission 
of  syphilis  to  the  unborn  infant.  As  this  matter  is  most  complicated, 
I  give  here  a  taljular  statement  of  the  manner  in  which  I  jnopose 
to  discuss  it,  to  serve  as  a  sort  of  mcmoria  tcchniea.  It  will 
be  noted  that  I  take  the  jKriods  of  antenatal  life  as  my  jniniary 
divisions : — 


PATHOGENESIS  245 

1.  FcETAL  Period. 

(a)  Transmitter. 

(b)  Mechanism  of  transmission. 

(c)  Results  of  transmission. 

(d)  Reverse  current. 

2.  Embryonic  Period. 

(a)  Transmitter. 

(b)  Mechanism  of  transmission. 

(c)  Results  of  transmission. 

3.  Germinal  Period. 

(1)  Unified  Epoch. 

(a)  Transmitter. 

(b)  ^Mechanism  of  transmission. 

(c)  Results. 

(2)  Dual  Epoch. 

(a)  Transmitter. 

(b)  Mechanism  of  transmission. 

(c)  Results  of  transmission. 

A  reference  to  the  scheme  of  antenatal  life  on  p.  8  \yill  serve  to 
explain  these  snb-divisious,  and  more  especially  those  of  the  germinal 
period. 

1.  Transmission  in  the  F(ital  Period. 

(«)  In  the  foetal  period,  which  may  be  regarded  as  extending 
(roughly)  from  the  end  of  the  sLxth  week  to  the  full  term,  there  are 
only  two  possible  transmitters  of  the  syphilitic  poison.  One  of  these 
"  possibles  "  is  at  once  evident — the  mother.  If  we  accept  for  syphilis 
the  same  possibilities  as  for  smallpox,  typhoid,  malaria,  measles,  and 
the  like,  then  it  must  be  regarded  as  certain  that  the  virus  of  the 
disease  will  in  some  cases  at  any  rate  pass  from  the  maternal  to  the 
fcetal  organism.  The  mother  who  is  syphilitic  transmits  syphilis  to 
her  foetus.  This  is  sometimes  called  the  maternal  variety  of  syphilitic 
heredity,  but,  as  I  have  already  stated,  I  prefer  not  to  use  the 
word  "  heredity  "  for  any  morbid  state  transmitted  after  the  occur- 
rence of  conception  (post-conceptionally).  With  regard  to  the  second 
possible  transmitter  there  is  no  such  ob\aousness  or  certainty  ;  but  I 
think  it  may  be  that,  so  to  say,  the  embryo  may  transmit  the  poison 
of  syphilis  to  the  fcetus.  The  embryo  may  have  been  infected  by  the 
mother  during  the  embryonic  period,  or  again  the  embryo  may  have 
had  an  infection  handed  on  to  it  from  the  germ  (fertilised  ovum) ; 
and  it  may  as  it  were  pass  it  on  to  the  foetus.  It  may  be  that  there 
was  no  time  for  the  poison  to  take  eftect  in  the  germinal  or  embryonic 
period,  or  its  effects,  if  there  were  any,  might  not  1  le  recognised  as  such  ; 
so  the  first  distinct  signs  appear  in  the  fcetal  state.  I  admit  that  this 
idea  of  transmission  is  unusual,  and  that  it  perhaps  implies  the  accept- 
ance of  the  theory  of  latency  ;  but,  to  my  mind,  it  seems  to  be  necessary 


246  ANTKNATAL    PATHOLOCIV    AM)    IIV(;!HNK 

if  we  are  to  accept  the  hypothesis  of  germ  and  sperm  infection  with 
syphilis. 

(h)  With  regard  to  the  mechanism  of  transmission  in  tlie  fii'tal 
period,  it  must,  if  the  mother  be  the  transmitter,  be  looked  ii])iin  as 
chietly  transplacental.  It  is,  of  course,  2'ossihlc  that  it  might  be 
through  the  li(iuor  amuii  or  transamniotic,  but  that  method  cannot 
be  common,  if  indeed  it  occur  at  all.  I  do  not  projjose  to  consider 
here  tlie  various  possibilities  of  transplacental  transmission  of  disease 
from  mother  to  fu'tus;  these  have  been  fully  dealt  with  in  Chapters 
XI.  and  XIII.  ("  placental  factor  in  fcetal  pathology,"  "  fo-lal  tubercle," 
etc.),  and  need  not  be  re-enumerated  for  fo'tal  sy])hilis.  Whether  or 
not  it  is  necessary  for  the  placenta  to  be  diseased  {>'.>/.  ha-morrliagic) 
in  order  that  the  virus  may  pass,  cannot  be  yet  regarded  as  a  settled 
question.  The  mechanism  of  transmission  from  embryo  to  foetus  is 
still  more  obscure  and  uncertain.  It  may  be  that  the  undiscovered 
"  microbe  "  or  "  fungus  "  of  syphilis  lies  latent  in  the  embryonic  tissues, 
and  is  thus  carried  over  into  the  foetal  period,  becoming  active  in  the 
fu^tal  organs  ;  but  here  the  maze  of  hypotheses  is  so  bewildering  that 
we  refuse  to  wander  further. 

(c)  As  to  results,  it  must  be  accepted  in  the  first  place  that 
the  fcetus  may  escape  infection  and  be  born  free  of  syphilis.  This 
has  been  shown  to  be  the  case  with  tubercle,  variola,  measles, 
typhoid,  and  other  maladies  which  are  transmissible,  and  analogy  as 
well  as  direct  clinical  evidence  lead  us  to  e.xpect  it  in  syphilis  also. 
Again,  and  this  is  no  doubt  what  most  often  haijpens,  the  poison  of 
syphilis  expends  its  full  virulence  upon  the  placental  tissue,  sets  up 
morbid  changes  in  it,  and  so  kills  the  foetus :  abortion  or  piremature 
labour  then  follows,  the  former  in  the  early  and  the  latter  in  the  later 
months  of  foetal  existence ;  or,  the  foetus  may  not  die  in  utero  but 
after  expulsion  as  a  result  of  its  prematurity.  Again,  we  may  suppose 
that  the  syphilitic  virus,  so  to  say,  forces  the  placental  barriers  and 
attacks  the  intracorporeal  foetal  organs ;  then  there  occurs  the  long 
.series  of  morbid  alterations  of  bone,  skin,  liver,  spleen,  blood,  kidneys, 
thymus,  etc.,  to  which  reference  has  been  made ;  and,  as  a  result  of 
this  syphilitic  infection  of  the  fietus,  it  is  expelled  alive  with  the  signs 
thereof  upon  it,  or  dies  in  utero  and  is  born  in  a  more  or  less  macerated 
condition.  Again,  the  foetus  may  at  the  time  of  l)irth  exhibit  not 
only  the  oi'dinaiy  signs  of  syphilis,  Init  also -some  of  the  syphilitic 
dystrophies  or  malformations ;  but  probably  the  dystrophies  will  be 
found  to  be  only  those  of  organs  which  are  in  an  emhi'vonic  or  form- 
ative state  in  the  foetal  period,  e.i/.  ears,  eyes,  genitals,  limbs,  etc. 
Once  more,  the  fcetus  may  lie  born  alive  and  only  show  external  signs 
of  syphilis  some  weeks  after  birth ;  or,  it  may  never  do  so,  and  may 
even  give  evidence  of  immunity  against  syjihilis. 

The  question  of  the  possible  transmission  of  immunity  has  caused 
much  discussion.  The  belief  that  a  mother  in  the  secondary  stage  of 
syphilis  can  confer  immunity  from  that  disease  upon  her  unliorn  infant, 
is  an  expansion  of  the  statement  made  by  Profeta  (and  liy  I'.eln-ciun 
that  a  healthy  cliild  born  of  a  syphilitic  motlier  can  be  nourished  safely 
liy  that  mother  or  by  a  syphilitic  nurse  ;  for  "  the  law  of  Profeta,"  as  it 


PATHOGF.NKSIS  247 

is  generally  called,  is  now  liekl  tn  be  that  healthy  children  born  of 
syphilitic  parents  are  not  susceptible  of  infection.  It  is  extremely 
doubtful  whether  in  its  expanded  sense  the  law  of  Profeta  can  be  ac- 
cepted as  the  statement  of  even  an  occasional  occurrence.  There  is  a 
certain  individuality  of  the  unborn  infant  to  be  taken  into  account 
which  is  independent  of  all  maternal  influence,  and  now  and  again  a 
case  of  innate  immunity  to  syphilis  may  occur.  Again,  it  has  been 
found  by  G.  Ogilvie  {Brit.  Journ.  Dcrmaf.,  xi.  45,  89,  1899)  and  others, 
that  of  reliable  evidence  in  favour  of  intrauterine  immunisation  there 
is  extraordinarily  little,  so  much  so  that  Buret  {Progres  med.,  3  s.,  xi. 
377,  1900)  declares  that  Profeta  has  made  a  hasty  generalisation  from 
a  few  cases,  and  that  he  has  been  deceived  by  a  mirage  ("  il  a  etc  la 
dupe  d'un  mirage  ").  On  the  other  hand,  there  is  a  fair  amount  of 
evidence  in  support  of  the  modified  belief  that  mothers  who  are 
syphilitic  before  conception  rarely  communicate  the  disease  to  their 
ofl'spiring  in  extrauterine  life ;  but  there  is  some  proof  that  in  post- 
conceptional  syphilis  (i.e.  maternal  syjjhilis  acquired  when  the  offspring 
is  in  the  foetal  period  of  his  antenatal  life)  the  child  may  be  contamin- 
ated by  the  mother  after  his  liirth.  It  is  only  with  this  last-named 
possibility  tliat  we  are  here  concerned.  There  are  so  many  possible 
fallacies  {c.r/.  difficulty  in  ascertaining  the  facts  of  the  case,  unknown 
modes  of  action  of  the  tissues  of  the  placenta  and  foetal  organs  on 
toxins  and  anti-bodies,  influence  of  treatment,  etc.)  that  it  seems  im- 
possible to  decide  for  or  against  the  "  law  of  Profeta,"  save  perhaps  to 
the  extent  that  it  is  at  any  rate  certain  that  it  is  not  "  a  law."  The  fact 
that  the  mother  is  in  the  tertiary  rather  than  in  the  secondary  stage 
during  her  pregnancy  does  not  simplify  matters  much.  Theoretically, 
it  may  be  reasonably  admitted  as  a  possibility,  that  a  pregnant  syphil- 
itic woman  may  occasionally  transmit  to  her  foetus  alexins  or  bodies 
which  enable  the  fcetal  organs  (including  the  placenta)  to  manufacture 
alexins  which  render  it  immune  to  syphilis  for  a  short  time  after 
birth.  The  last  point  is  to  be  emphasised,  for  Hutchinson  {Tv-enticth 
Century  Practice,  xviii.  396,  1899)  and  others  freely  admit  that  im- 
munity although  possible  is  only  temporary.  Analogy  with  vaccinia 
and  malaria  and  possibly  tubercle  in  pregnancy  supports,  although 
not  very  strongly,  the  theory  of  occasional  intrauterine  immunisation. 
Among  the  most  curious  results  of  transmission  must  be  placed 
those  which  occur  when  twins  are  found  in  the  uterus.  When  both 
twins  become  syphilitic  no  need  for  surprise  exists ;  but  when  the  in- 
fants are  born  showing  syphilis  in  very  different  degree,  or  still  more, 
when  one  twin  is  born  healthy  and  remains  so  while  the  other  is 
manifestly  syphilitic,  the  occurrence  seems  incongruous  and  even 
grotesque.  Such  observations  have  been  several  times  recorded,  as 
Alfred  Fournier  (L'herdditc  sypMlitiquc,^.  294, 1891)  and  others  have 
shown.  No  very  satisfactory  explanation  can  be  found,  indeed 
Fournier  (op.  cit.,  p.  296)  says  "  c'est  la  une  cnigme  de  plus  dans  un 
sujet  qui  en  comporte  un  si  grand  nombre  "  ;  but  it  may  be  remarked 
that  if  the  mother  can  transmit  immunising  material  to  her  fcetus,  it 
is  possible  that  one  fcetus  of  twins  (the  one,  for  instance,  with  the 
stronger  heart)  may  conceivably  cause  alexins  or  antitoxins  to  pass 


248  ANIKNA'IAL    I'A  lli()I.()(;V    AND    IIYCUKNK 

to  the  otlier  fu-tus.  This  oxplaimliuu  (or  sJiaduir  of  an  explaiiatiou), 
however,  will  scarcely  hold  in  the  case  where  the  jilacentas  are 
separate.  If  the  so-called  "  law  of  Profeta  "  had  been  found  to  he 
a  law,  we  might  have  expected  another  "  law"  that  the  healthy  twin 
in  cases  of  syphilis  would  show  immunity  from  tiie  disease  after 
birth!  "  Une  I'uigme  de  plus!"  It  may  be  noted  here  that  the 
infection  of  one  of  two  fu-tuses  in  utero  is  not  a  phenomenon  observeil 
in  syphilis  only  ;  it  has  been  recorded  in  connection  with  fo'lul 
variola  (ride  y.  190). 

{d)  liut  no  allusion  has  yet  been  made  to  what  may  be  called  the 
"  reverse  cm-rent  "  of  infection  in  fo'tal  life,  to  what  has  been  termed 
"  syphilis  par  conception,"  "  conceptional  syphilis,"  "  syphilis  by  cliuc 
en  retour,"  or  "  maternal  retro-infection."  Whether  or  not  this  re- 
verse current  of  infection  from  fa>tus  to  mother  exists,  has  been  the 
subject  of  great  controversy,  and  of  the  most  extraordinary  diver.sity 
of  opinions,  and  it  must  also  be  admitted  of  a  most  regrettable  amount 
of  theorising  from  most  insufficient  data,  indeed  from  no  data  at  all. 
Some  few  things  seem  fairly  certain  among  much  that  is  most  un- 
certain. They  are  these.  There  is  a  physiological  reverse  current 
from  firtus  to  mother  whereliy  efi'ete  materials  and  carbonic  acid  are 
carried  to  the  ]dacenta  and  thence  pass  through  it  into  the  maternid 
circulation  {oidc  p.  Wo).  There  would  also  appear,  from  experi- 
mental evidence,  to  lie  a  matripetal  current  carrying  such  poisons  as 
strychnine,  curare,  hydrocyanic  acid,  etc.,  from  the  fo'tus  {ridr  pp.  168, 
164).  Finally,  there  is  some  slight  experimental  evidence  in  support 
of  the  belief  that  the  toxins  of  the  bacillus  pyocyaneus  and  of 
diphtheria  may  likewise  reach  the  maternal  circulation.  When, 
however,  we  leave  the  fairly  firm  ground  on  which  these  statements 
rest,  we  find  ourselves  in  a  veritable  quagmire  of  hypotheses,  in  a 
shifting  .sand  of  theories.  This  nmch,  I  suppose,  may  be  said  with 
some  slight  degree  of  confidence.  When  a  mother  infects  her  ftctus 
transplacentally  with  syphilis  and  this  sets  up  syphilitic  processes  in 
the  fcctal  organs  and  tissues,  it  is  quite  possible  that  toxins  formed  in 
the  fretal  bodj'  may  pass  through  the  placenta  into  the  maternal 
organism  ;  it  seems  even  strongly  ])robable  that  this  occurs.  It  may 
also  be  believed  that  such  toxins  thus  reaching  the  mother  may  liave 
some  injurious  effect  upon  her;  in  foetal  smallpox  there  is  some 
evidence  that  the  maternal  fever  is  increased  when  the  fcetus  is  in 
the  sujipurative  stage.  But  the  supporters  of  the  reverse  current  go 
much  further  than  this:  they  imagine  a  healthy  mother  becoming 
infected  through  her  firtus,  she  herself  being  up  till  then  free  from 
infection.  It  is  supposed  that  the  father  was  syi)hilitic  at  the  time  of 
fruitful  coitus,  and  that  tlirongh  his  infected  sperm  the  impregnated 
ovum  also  was  infected,  that  the  infection  lay  latent  in  the  germ  and 
embryo  till  the  fu>tal  period,  and  that  then  syphilis  develupcd  in 
the  fa?tus  and  infection  of  the  mother  through  the  placenta  followed 
by  virtue  of  the  reverse  current.  This  theory  is  neces.sary  in  order  to 
offer  an  explanation  of  the  cases  in  which  a  ))regnant  woman,  pre- 
viou-sly  non-syphilitic  to  all  appearance,  develops  the  secondaries 
(sometimes     the     tertiarics)     of    syphilis     during     her    pregnancy, 


PATHOGENESIS  249 

apparently  witliout  any  precedent  primary  sore  or  chancre.  The 
maternal  disease  thus  acquired  manifestly  lacks  the  primary  stage, 
antl  in  its  abbreviated  form  is  called  "  syphilis  decapitce,"  an  acephalic 
syphilis  so  to  say.  (Too  much  need  not,  however,  be  made  of  this 
headless  condition  of  so-called  coneeptional  sypliilis,  for  the  syphilis 
whicli  develops  in  the  fojtus  in  utero  is  also  always  a  decapitated 
syphilis).  Manifestly  the  acceptance  of  this  view  entails  the  belief 
that  the  father's  syphilis  (even  in  a  latent  condition)  can  be  passed 
on  through  the  ovum  and  embryo  and  f(etus,  and  infect  the  maternal 
organism  in  this  circuitous  manner — circuitous  as  to  route,  delayed 
as  to  time.  This  is  just  the  crux  of  the  whole  matter ;  and  while 
tliere  are  some  who  admit  this  direct  paternal  infection  of  the  germ 
with  transmission  onwards  to  the  fcetus,  there  are  others  who  stoutly 
maintain  its  impossibility.  Manifestly,  there  are  only  two  possible 
transmitters  of  syphilis  to  the  foetus  in  the  foetal  period,  the  mother 
and  the  embryo,  and  the  embryo  must  have  got  the  infection  origin- 
ally from  either  the  mother  or  the  father.  With  the  question  of 
germinal  infection  I  deal  later  :  but  if  we  postulate  germinal  patei'nal 
contagion,  then  w"ith  regard  to  the  possibility  of  that  contagion  being 
handed  tlown  from  germ  to  embryo  and  from  endjryo  to  foetus,  and 
then  at  last  infecting  the  mother,  all  that  can  be  safely  said  is  that  it 
is  of  course  possible,  but  its  mechanism  is  outside  ordinary  physio- 
logical laws  of  transmission  and  requires  the  assumption  of  the  genesis 
of  heredity. 

But  coneeptional  syphilis  is  not  the  only  result  that  may  follow 
upon  the  presence  in  utero  of  a  syphilitic  ftvtus.  It  has  been  noticed 
that  if  an  apparently  healthy  mother  give  birth  to  an  undoubtedly 
syphilitic  infant  she  may  nurse  that  infant  with  impunity,  in  other 
words,  she  does  not  develop  a  mammary  chancre.  This  has  been  called 
Colles'  or  Baumes'  law ;  and,  like  many  other  things  in  connection 
with  antenatal  syphilis,  it  has  been  the  occasion  of  no  small  difference 
of  opinion.  Little  wonder !  The  phenomena  of  the  transmission  of 
diseases  are  difficult  indeed  and  capable  of  being  interpreted  in 
various  ways,  but  when  we  come  to  consider  the  phenomena  of  the  trans- 
mission of  immunity  against  diseases,  the  difficulties  are  multiplied 
and  the  possiljle  divergencies  of  interpretation  are  greatly  increased. 
And  yet  the  antenatal  pathologist  has  to  struggle  with  these  difticul- 
ties.  Will  the  reader  bear  with  the  writer  in  his  poor  efforts  to  bring 
some  order  out  of  the  "  rudis,  indigestaqne  moles  "  of  this  subject  ? 

Maternal  immunity  against  syphilis  may  be,  to  begin  with,  an 
idiosyncrasy  possessed  by  her ;  under  these  circumstances  the  presence 
of  a  syphilitic  foetus  in  her  uterus  will  neither  give  her  syphilis  nor 
can  it  be  described  as  conferring  upon  her  an  immunity  against 
syphilis,  for  that  she  already  has.  It  is  possible  that  some  cases 
regarded  as  instances  of  Colles'  law  may  be  explained  thus.  In 
the  next  place,  it  is  possible  that  the  mother  may  take  from  her 
foetus  a  latent  form  of  syphilis,  or  that  she  may  already  be  suffering 
from  the  disease  in  a  latent  state ;  at  a  later  period,  namely  after 
lactation  is  over,  she  may  show  tertiary  sympitoms,  or,  on  the  other 
hand,  by  that  time  the  latency  of  the  disease  may  have  become  a 


250  AX'rF.XATAI,    I' A  IHOLOCIY    AND    HVdIF.NE 

j)eniuui(jul  iiaiiiuiiily.  (All  liypotliL'.sus,  (J  t'liciully  ii-iuler  1)  Again, 
it  may  be  tliat  the  mother  has  acquired  immunity  from  the  fa'tus, 
that  she  lias  been  rendered  immune  liy  the  toxins  or  antitoxins  m 
anti-bodies  coming  to  her  through  the  placenta  from  the  foetus  (c/'/i 
K.  von  Diiring,  Monatsrlu:  f.  lyi'dli.  Dermat.,  xx.  245,  1895).  Tin- 
mechanism  of  this  immunisation  I  must  leave  unexplained,  fur 
physiology  has  not  worked  out  the  matter  yet,  but  ap])arently  it  is 
necessary  to  regaixl  it  as  either  transjjlacental  or  transamniotic.  But 
yet  again,  the  maternal  immunity  may  l)e  capable  of  another  explana- 
tion. It  may  be,  as  Boulengier  {Jouni.  d.  mal.  cutan.  ct.  syph.,  2  s., 
vii.  722,  1895)  supposes,  that  the  mother  really  takes  syphilis,  but 
that  all  the  strength  of  the  virus  is  exerted  upon  the  very  active 
organs  of  the  f(ctus  (placenta  included),  which  are,  as  it  were,  a  most 
favourable  culture  medium  for  it ;  according  to  this  supposition,  the 
mother  has  really  given  syphilis  to  the  foetus,  it  has  passed  through 
her  without  touching  her,  and  there  is  then  no  need  to  sui)]>ose  that 
the  foetus  obtained  either  the  disease  or  the  power  to  infect  or 
immunise  the  mother  from  the  father.  It  is  a  little  difficult  to 
accept  Boulengier's  further  conclusion,  that  the  foetus  who  has  got 
the  disease  in  this  sort  of  unconscious  way  from  the  mother  can  then 
actively  immunise  the  mother ;  but,  as  he  himself  says,  it  is  "  hypothese 
pour  hypothese,"  and  who  knows  ! 

After  all,  CoUes'  law  is  not  absolutely  a  law '  Exceptions  to  it 
have  been  reported  {cfj.  by  Drennen,  Juurn.  of  Cutan.  and  Gcn.- 
Urin.  Bis.,  xv.  p.  125,  1897  ;  by  J.  A.  Coutts,  laticet,  i.  for  1894,  p. 
1443;  by  Neuhaus,  Monatschr.  f.  pralct.  Dermat.,  xxviii.  p.  616,  1899; 
and  by  several  others).  We  may  take  Jonathan  Hutchinson's  con- 
clusions (Tiventieth  Centura/  Practice,  xviii.  p.  375,  1899)  on  this  matter 
as  being  practical  and  as  near  to  the  truth  as  it  is  at  i:)resent  pos- 
sible to  get, — namely,  that  the  apparently  healthy  mother  may  nurse 
her  syphilitic  child,  the  risk  to  lier  is  iniinitesimal  wliile  the  gain  to 
the  child  is  incalculable,  hut  the  risk  is  not  absolutely  excluded. 
Possibly  the  exceptions  to  Colles'  law  may  be  due  to  a  morliid  con- 
dition of  the  placenta ;  possibly  also  the  occurrence  of  cases  showing 
Colles'  law  may  be  due  to  a  morbid  condition  of  the  placenta.  The 
reader  may  even  make  his  own  choice  '  In  all  this  bewildering 
subject  it  will  be  well  to  remember  that  it  is  always  very  ditticult  to 
get  the  truth,  the  whole  truth,  and  nothing  but  the  truth,  from 
syphilitic  patients,  and  that  still  even  on  the  part  of  the  physician 
skilled  in  clinical  methods  humaiudn  est  errecrc. 

2.  Transmission  in  the  Embryonic  I'ekiod. 

(a)  In  the  embryonic  period  of  antenatal  life  (roughly  tiic  first 
six  weeks,  nun-e  exactly  the  time  between  the  formation  of  the  first 
rudiments  of  the  embryo  in  the  embryonic  area  and  the  a])pearance 
of  the  transition  organism,  ride  p.  7),  there  can  be  little  doubt  that 
syphilis  in  the  mother  produces  an  effect  upon  the  organism  in  her 
uterus.  The  mother  in  this  period,  as  in  the  fwtal,  must  be  the  chief 
transmitter.     At  the  same  time  it  is  possible  that  the  emljryo  may  lie 


PATHOGENESIS  251 

iufectt'il  from  the  germ,  and  the  germ  in  its  turn  eitlier  from  the 
father  or  the  mother ;  it  is  even  possible  that  the  syphilitic  peccant 
matter  (microbe,  "fungus,"  toxin)  may  exist  in  the  spermatic  Muid 
alongside  of  the  spermatozoa,  and  may  prove  the  means  of  infecting 
the  embryo  directly  after  its  germinal  life  is  finished.  Of  this,  how- 
ever, more  anon. 

(b)  As  to  the  mcclianisvi  of  transmission,  in  this  early  period  very 
little  can  be  said  with  even  a  shadow  of  confidence.  Probably  the 
virus  will  travel  again  in  the  blood  stream  from  mother  to  tlecidual 
membranes,  and  will  sometimes  pass  their  barriers  to  reach  the 
embryo  either  by  the  omphalo-mesenteric  veins,  the  allantoidal  (umbil- 
ical) vein,  or  (doul)tfully)  by  the  liquor  amnii.  From  the  practical 
point  of  view  of  immediate  results  it  will  matter  little  whether  it 
reach  the  embryonic  organism  or  not,  for  the  decidual  membranes 
are,  as  regards  the  continuance  of  antenatal  life,  the  really  vulnerable 
part.  How  the  syphilitic  microbe  or  toxin  is  carried  over  from  the 
germ  into  the  embryo  and  its  membranes,  we  do  not,  of  course,  know ; 
possibly  it  is  latent  in  the  germinal  period,  possibly  it  sets  up 
changes  in  the  germinal  period  which  are  simply  continued  in  the 
embryonic. 

(c)  The  results  upon  eml)ryonic  life  no  doubt  vary.  In  the  first 
place  there  may  be  abortion  due  to  changes  in  the  decidual  mem- 
branes ;  this  may  well  be  believed  to  be  very  common.  It  may  be 
preceded  Ijy  embryonic  death,  but  of  this  little  or  no  evidence  is 
forthcoming.  At  any  rate,  the  occurrence  of  abortion  is  equivalent 
to  embryonic  death.  In  the  second  place,  it  is  possilile  that  it  may 
be  the  cau.se  of  dwarfing  or  non-development  of  the  embryo ;  and,  in 
the  third  place,  from  what  is  known  of  experimental  teratogenesis 
taken  in  conjunction  with  clinical  experience,  it  is  very  probable  that 
the  syphilitic  poison  coming  into  contact  with  the  forming  organs  of 
the  emljryo  will  cause  them  to  form  badly  and  so  produce  malforma- 
tions and  monstrosities.  These  matters  will  be  more  fitly  described  in 
the  part  of  this  work  which  deals  with  the  pathology  of  the  emlnyo ; 
they  are  introduced  here  simply  to  complete  the  survey  of  the  possible 
modes  of  transmission  of  syphilis  to  the  foetus. 

3.  Transmission  ix  the  Geemixal  Period. 

The  germinal  period,  it  will  be  remembered  (if  the  reader  does 
not  recollect,  let  him  consult  pages  8,  9,  and  10),  consists  of  two 
divisions,  a  long  period  prior  to  impregnation,  and  a  very  short  but 
very  active  period  following  after  impregnation.  In  the  former  or 
ante-conceptional  period,  there  is  the  dual  life  of  the  spermatozoon 
and  the  ovum  ;  in  the  latter  or  post-conceptional  period,  there  is  the 
unitied  life  of  the  impregnated  ovum.  In  the  former  the  locus  of  the 
hfe  is  the  interior  of  the  sexual  gland  (ovary  or  testicle) ;  and  in  the 
latter  it  is  the  interior  of  the  uterus,  and  for  a  short  time  the  interior 
of  the  Fallopian  tube  (that  is,  if  we  regard  impregnation  as  occurring 
prior  to  the  arrival  of  the  ovum  in  the  uterus). 

Let  us  consider  the  possible  transmitters  of  syphilis  in  this  germinal 


252  ANTKXATAI,    I'A  rHOl.Od'i     AND    incUJ-.NK 

period  ul'  ;iuleiial;il  lifo:  and  now,  for  thu  first  time,  we  are  brouulit 
face  to  face  with  the  large  problem  of  the  direct  influence  of  the 
father  in  infection.  But  let  us  deal  first  witli  the  mother  as  triins- 
mitter.  It  is  possible  that  the  syphilitic  virus  in  the  maternal  uterus 
or  Fallopian  tube  may  infect  the  ovum  as  it  is  being  transfernd 
from  the  ovary  to  the  uterine  interior ;  it  is  possible  also  that  the 
ovum  may  be  already  impregnated  before  it  leaves  the  ovi-sac. 
These  things  are  possible,  but  he  would  be  foolhardy  who  ventured  to 
state  them  as  facts.  Our  knowledge  of  the  action  of  microbes  and 
toxins  upon  the  human  ovum  either  before  or  after  impregnation  is 
practically  nil;  we  are  again,  thei-efore,  wandering  in  a  maze  of 
theories.  But,  and  this  is  the  important  point,  all  the  observers  and 
writers  who  have  dealt  with  this  matter  have  not  kept  in  mind  that 
it  is  a  maze  of  liypotheses  ;  some,  in  fact,  have  made  extraordinarily 
confident  assertions  about  its  most  doul>tful  parts.  ]Many  of  them 
seem  to  forget  that  no  one  has  ever  seen  the  penetration  of  the  human 
ovum  liy  a  spermatozoon!  It  has,  of  course,  been  shown  experi- 
mentally that  tubercle  bacilli  may  be  introduced  into  the  hen's  egg, 
and  that  the  bacilli  may  apparently  remain  latent  in  the  embryo 
chick,  setting  up  tuberculosis  only  after  the  chicken  has  left  the  egg; 
but  there  is  a  great  distance  between  such  an  experiment  and  the 
assertion  that  a  syphilitic  microbe  can  pass  from  the  mother  into  an 
ovum  in  one  of  her  ovaries  and  set  up  syphilis  in  the  fcctus  that 
develops  from  that  ovum.  We  cannot  deny  its  jjossibility ;  we  may 
even,  from  clinical  evidence,  be  very  sure  that  something  producing 
such  a  result  does  occur ;  but  the  slenderness  fif  the  evidence  and 
the  lack  of  knowledge  of  the  mechanism  must  ne\'er  be  forgotten. 

Similar  remarks  apply  to  the  theories  of  the  father  as  trans- 
mitter of  syphilis,  either  alone,  or  more  often  in  conjunction  with  the 
mother.  The  idea  which  seems  to  be  present  in  the  mind  of  those 
who  believe  in  infection  of  the  foetus  a  patrc  is  that  of  a  spermato- 
zoon carrying  a  bacillus  or  a  toxin  of  syphilis  with  it  into  the  ovum, 
and  at  one  and  the  same  time  impregnating  the  ovum  and  inoculating 
the  new  organism  with  syphilis.  This  hypothesis  of  bacilliferous 
spermatozoa  and  their  effects  may,  of  course,  turn  out  to  be  correct; 
but  it  has  to  be  remembered  that  it  is  purely  hypothetical.  What 
happens  when  Viacilli  are  brought  into  contact  with  spermatic  fluid  ? 
What  follows  when  a  spermatozoon  is  penetrated  by  one  or  more 
bacilli  ?  Does  the  sexual  cell  eat  them  or  do  they  weaken  the  sexual 
cell  ?  Must  it  not  be  very  unlikely  that  the  bacilliferous  spermato- 
zoon shall  be  also  the  impregnating  spermatozoon  ?  Does — but  let 
us  get  out  of  the  maze  of  hypothetical  cross-questions  again  if  we 
can.  The  evidences  of  purely  paternal  infection  may  be  enumerated 
as  follows : — (1)  The  occurrence  of  cases  of  fu'tal  syphilis  in  which  the 
father  alone  was  syphilitic  (a  very  rare  occurrence,  let  it  be  remem- 
bered);  (2)  the  frequency  of  abortions  when  the  father  is  syphilitic 
and  the  mother  healthy,  the  abortions  being  regarded  as  evidence  of 
syphilis :  (3)  the  good  effects  of  anti-syphilitic  treatment  of  the  father 
alone  in  such  cases,  future  pregnancies  going  on  to  the  full  term : 
ami    (4)    tile  infection  of  the  mother  liy  her  f'o'tus  or  conceptioual 


pathoc;enesis  253 

syphilis,  on  the  supposition  that  in  such  instances  the  germ  has  been 
directly  infected  by  the  father.  As  a  proof  of  direct  paternal 
infection  of  the  germ,  this  last  occurrence  must  be  left  out  of  account ; 
but  the  other  three  pieces  of  evidence  have  a  certain  value,  a  value 
so  great  as  to  make  many  believe  in  the  possibility  of  direct  paternal 
infection  without  being  able  to  offer  any  satisfactory  explanation  of 
its  meclianism.  On  the  other  hand,  cases  supporting  the  view  are 
admittedly  very  rare,  and  sometimes  a  syphilitic  (even  a  recently 
syphilitic)  father  neither  gives  his  wife  syphilis  nor  procreates  a 
syphilitic  fcetus.  Further,  frequent  abortions  do  not  of  necessity 
indicate  the  existence  of  syphilis,  while  the  results  of  treatment  are 
of  necessity  of  the  nature  of  post  Jioc  enjo  propkr  /i op  evidence.  It 
has  been  said  also  that  animals  cannot  be  inoculated  with  diseased 
spermatic  fluid;  but,  as  A.  Foui-nier  {L'MvMih'  syphilitique,  p.  49, 
1801)  reminds  us,  inoculation  of  the  subcutaneous  tissue  is  one 
thing,  and  impregnation  of  an  ovum  is  another  and  a  very  different 
thing. 

The  reader  will,  I  think,  have  by  this  time  come  to  the  con- 
clusion at  which  the  writer  has  arrived,  that  direct  paternal  infection 
of  the  germ  (ovum  or  ovo-sperm)  with  syphilis  can,  in  the  present 
state  of  our  knowledge,  neither  be  proved  nor  disproved — it  must  be 
left  unsettled,  lying,  as  Fournier  says,  as  "  une  veritable  pomme  de 
discorde  jetee  clans  le  camp  des  observateurs."  It  may  be  added  that 
direct  paternal  infection  has  been  afdrmed  in  foetal  malaria,  tubercle, 
and  even  in  fo?tal  smallpox  {vide  pp.  203,  216,  and  190). 

From  what  has  been  written  regarding  the  transmitters  in  the 
germinal  period,  it  will  be  gathered  that  nothing  of  any  importance, 
nothing  at  any  rate  with  any  certainty,  can  be  affirmed  about  the 
mechanism  of  transmission  in  this  epoch.  We  may  imagine  the  ovum 
or  spermatozoon  bathed  in  syphilis-infected  fluid  and  absorbing  or  being 
penetrated  by  the  fluid  or  its  bacilli;  hut  it  is  a  vision  which  may  or 
may  not  be  a  foreshowing,  but  still  indubitably  a  vision. 

Then,  as  to  results.  Again,  the  antenatal  pathologist  must  plunge 
neck  deep  into  a  morass  of  hypotheses  and  conjectures.  Theoretic- 
ally, it  is  to  be  expected  that  the  results  of  syphilitic  infection  in 
the  germinal  period  will  differ  very  markedly  from  those  following  a 
later  infection.  Possibly  they  may  take  the  form  of  unrecognised 
(because  so  precocious)  abortions,  and  of  anomalies  in  the  formation 
of  the  decidual  and  fcetal  membranes  (hydatid  mole) ;  possibly,  also, 
the  syphilis  may  lie  latent  and  only  cause  morbid  changes  in 
embryonic  or  fcetal  life.  This  matter,  however,  will  be  returned  to 
again  in  the  discussion  of  the  pathology  of  germinal  life.  In  the 
meanwhile  the  antenatal  pathologist  may  scramble  out  of  his  morass 
of  hypotheses  and  rejoice  to  be  once  more  on  firm  earth ;  it  may  turn 
out  to  be  only  a  little  island  he  has  reached  in  the  midst  of  his 
([uagmire,  and  that  he  will  be  found  floundering  again  almost  immedi- 
ately ;  but  for  the  time  he  has  a  firm  foothold.  I  have  said  what 
had  to  be  said  regarding  the  pathogenesis  of  fcetal  syphilis,  and  must 
now  look  at  some  of  the  effects  of  the  disease. 


254  AXTKNAIAI.    PA  II  l()L()(iV    AND    HVCUENl", 


Effects  of  Foetal  Syphilis. 

The  effectK  of  KVphilis  upon  aiiloiialiil  life  are  so  serimis  as  to 
lead  writers  to  search  the  vocabularies  of  their  various  languages  for 
words  strong  enough  to  express  tlie  degree  of  gravity  arrived  at. 
Fournier,  for  instance,  writes  in  the  following  sentences  of  these 
results  : — "  La  syphilis  est  essentiellement  uieurtriere  pour  la  jeuiie 
age ;  elle  fait  de  veritables  hecatonibes  d'eui'ants :  elle  les  tue  avant 
la  naissance,  au  moment  de  la  naissance,  apres  la  naissance,  dans  les 
premieres  semaines  on  pendant  les  premieres  annes  (hen'do-syphilis). 
Mais  ce  qu'il  y  a  le  plus  a  redouter  ce  sont  I'avortement  syphilitique 
et  la  polymortalitu  infantile"  [Bchjique  Med.,  Ann.  vi.  p.  711,  1899). 
It  cannot  be  said  that  Fournier's  language  exaggerates  the  baneful, 
murderous,  and  malignant  effects  of  syphilis  on  antenatal  life,  and  it 
is  easy  to  agree  with  him  when  he  says  that  syphilis,  alcoholism,  and 
tubercle  "  constituent  la  triade  des  pestes  contemporaines." 

At  any  one  of  the  three  periods  of  antenatal  life  syphilis  may 
prove  murderous ;  it  may  kill  the  germ,  it  may  lead  to  the  casting  ott' 
of  the  embryo  in  a  recognised  or  unrecognised  abortion  sac ;  it  may 
kill  the  fatus  either  directly  or  by  leading  to  its  premature  expulsion 
from  the  uterus ;  and  it  may  send  the  infant  forth  into  its  extra- 
uterine environment  so  weak  or  so  diseased  as  to  entail  its  early 
demise.  It  may  also  permit  an  extrauterine  life,  but  one  rendered 
so  miserable  by  deformity  and  weakness  as  to  lie  almost  less  to  Ije 
desired  than  early  death.  These  are  some  of  its  ordinary  and 
manifest  effects,  and  they  do  not  include  the  evils  that  may  come 
upon  others,  or  even  the  later  ill-effects  of  the  dire  malady  upon 
the  individual  himself  (syphilis  hereditaria  tarda).  For  instance, 
a  healthy  mother,  who  has  escaped  direct  infection  from  her 
husband,  may,  if  we  accept  the  possibility  of  conceptional  syphilis,  ' 
receive  the  poison  from  the  infant  in  her  womb,  becoming  infected 
because  she  is  about  to  become  a  mother.  Again,  there  are  the  late  ' 
developments  of  congenital  syphilis,  including  the  so-called  Hutchin- 
sonian  triad  of  (1)  malformed  teeth,  (2)  ocular  inHammation,  and  (3)  ' 
ear  disease,  especially  otitis  media,  as  well  as  obscure  mental  conditions 
and  nervous  maladies,  and  the  predisposition  to  suiier  severely  fimii  ' 
many  other  diseases. 

And  yet  the  list  of  possible  evil  effects  is  not  finished  1  There  is 
some  reason  to  suspect  that  syphilis  may  pass  on  (without  any  ' 
fresh  infection)  to  the  next  generation.  Concerning  "  syphilis  of  the  ' 
third  generation,"  as  it  is  called,  there  is,  of  course,  no  lack  of  ditler- 
ence  of  opinion.  If  it  be  true  that  the  virus  can  thus  pass  from  the 
child  of  a  syphilitic  parent  to  the  grandchild,  then  it  would  seem  to 
imply  that  at  birth  the  ova  in  the  ovaries  of  a  syphilitic  infant  are 
already  infected.  Cases  in  which  transmission  to  the  third  genera- 
tion was  alleged  have  been  recorded  l)y  a  consideralile  ntnnbcr  of 
observers,  and  thirty-eight  of  these  cases  have  been  collected  by 
F.  de  Armenteros  (These,  Paris,  1900);  and  the  consideration  of  the 
clinical  evidence  therein  contained  would  lead  us  to  the  conclusion 
that    the    manifestations   of  this  retransmitted    syphilis  are  of  the 


EFFECTS   OF   F(KTAL   SYPHILIS  255 

nature  of  abortions,  dystrophies,  malformations,  monstrosities,  and 
even  of  the  more  ordinary  syphilitic,  visceral,  and  cutaneous  lesions. 
But  there  is  always  one  weak  link  in  the  choin  of  evidence  brought 
forward  to  prove  these  cases  ;  the  putative  parent  may  not  have 
been  the  real  parent. 

Surely  Fournier  has  not  used  too  strong  language  in  describing 
the  results  of  antenatal  syphilis !  But  even  the  efl'ects  that  have 
been  enumerated  do  not  end  the  tale  of  disaster,  for  national  life  and 
prosperity  also  suffer  from  this  antenatal  malady,  and  a  fall  in  the 
birth-rate  acconqianied  liy  an  increase  in  infantile  mortality  cannot 
be  lightly  regarded  by  social  economists.  Again  and  again  we  read  of 
cases  in  which  syphilis  has  so  affected  the  results  of  marriages  as  to 
give  from  fifty  to  a  hundred  2}cr  cent,  of  dead-born  or  quickly  perish- 
ing infants.  The  record  (sad  record  indeed !)  for  the  present  seems 
to  be  nineteen  dead  infants  as  the  result  of  nineteen  pregnancies. 
(D'Aulnay,  Arch,  dc  toco/,  ct  de  ijijncc.,  xxi.  p.  910,  1894).  "Well  may 
Fournier  exclaim,  "  Quelles  statistiques !  Quelles  horribles  tables 
mortuaires ! "  If  we  take  even  the  average  results  (private  and 
hospital  practice),  we  find  them  to  be  46  per  cent,  of  the  pregnancies 
ending  disastrously,  with  an  infantile  mortality  of  42  per  cent. 
Of  course  these  results  are  intiuenced  to  a  large  extent  by  circum- 
stances. Let  us  then  try  to  ascertain  what  the  modifying  circum- 
stances are. 

Among  the  circumstances  which  modify  the  effects  of  syphilis 
upon  antenatal  life  we  may  place, /?•«<,  the  age  of  the  pregnane}'  when 
the  infection  takes  place.  If  we  divide  the  evil  effects  into  deaths, 
and  deaths  plus  syphilitic  manifestations,  we  find,  according  to 
Fouruier's  tables,  that  when  infection  has  occurred  before  conception 
the  mortality  is  65  per  cent,  and  the  morbidity  70  per  cent. ;  when 
conception  and  infection  have  occurred  simultaneously  (a  hypothesis), 
the  mortality  is  75  per  cent,  and  the  morbidity  91  per  cent.;  while, 
when  the  infection  has  taken  place  after  conception,  the  mortality  is 
39  per  cent,  and  the  morbidity  72  per  cent.  "We  may  draw  the  con- 
clusion, therefore,  tliat  so  far  as  antenatal  life  and  health  are  concerned 
the  most  disastrous  results  are  due  to  infection  in  the  germinal  period, 
and  the  least  disastrous  to  post-conceptional  infection.  It  has  been 
maintained  by  some  that  maternal  syphilis  acquired  in  the  last  three 
or  last  two  months  of  pregnancy  spares  the  unborn  infant,  but  un- 
fortunately there  is  evidence  to  show  that  even  then  "  la  syphilis  est 
meurtriere  pour  la  jeune  age."  It  may  be  said,  however,  that  syphilis 
acquired  post-conceptionally  is  more  dangerous  for  subsequent  off- 
spring than  for  the  fretus  then  in  utero. 

In  the  second  place,  the  results  are  modified  by  the  transmitter. 
To  quote  from  Fournier's  tables  again,  when  the  transmitter  is  the 
father  alone,  the  mortality  is  28  per  cent,  and  the  morbidity  ("  noci- 
\'ite  ")  .■•!7  per  cent. ;  where  the  transmitter  is  the  mother  alone,  the 
figures  are  60  per  cent,  and  80  per  cent. ;  and  where  both  parents 
may  be  supposed  to  transmit,  the  mortality  reaches  the  high  figure  of 
68-5  per  cent,  and  the  morbidity  the  appalling  height  of  92  per  cent. 
There  is  then  an  ascending  scale  of  disaster  in  which  both  the  mortality 


L'56  ANl'KNAr.M.    I'ATHOI.OdY    AM)    H'XllKNi: 

and  the  iuJux  of  liannfuhiess  reach  a  iiiaximuiiL  wlien  hoth  parents 
are  transmitters,  while  the  mininiuni  is  found  when  the  fatlier  aluiic 
transmits.  Of  course,  we  must  not  forget  that  some  writers  do  iidt 
admit  paternal  infection  ;  but  tlie  statistics  given  are  comi)iled  from 
cases  in  which  the  father  was  apparcntlij  the  sole  transmitter. 

In  the  third  place,  the  age  of  tlie  syphilis  in  the  transmitter  would 
appear  to  have  a  modifying  ett'ect  ujum  the  results  to  the  fictu.s. 
It  would  seem  that  the  three  years  following  infection  are  much 
more  fatal  to  pregnancies  and  their  results  than  any  later  tliree  years. 
More  than  this,  the  first  year  is  by  far  the  worst  of  the  three.  It  is 
during  this  period  that  the  disease  is  in  the  stage  of  the  secondaries. 
The  first  year  after  infection  Fournier  terms  "  lannce  terrible,"  and 
with  good  reason  '  Of  ninety  women  infected  b}-  their  husbands  and 
who  became  pregnant  during  the  year  following  their  infection,  fifty 
aborted  or  had  dead-born  infants,  thirty-eight  gave  birth  to  children 
who  soon  died,  and  only  two  gave  birth  to  infants  who  survived.  As 
the  syphilis  Ijecomes  older  the  danger  to  the  product  of  conception 
becomes  less,  and  the  question  at  once  arises  whether  there  is  any 
age  beyond  which  lies  complete  safety  to  the  fcetus.  There  seems  to 
be  no  doubt  that  transmission  may  occur  even  when  syphilis  is  in  the 
stage  of  the  tertiaries  ;  but  in  the  case  of  the  father  two  years  would 
appear  to  be  a  working  limit,  so  to  say,  to  the  power  of  transmitting, 
while  in  that  of  the  mother  it  may  be  extended  to  seven  or  eight  years. 
Of  course,  exceptional  instances  have  been  recorded  of  transuussiou  by 
either  parent  after  much  longer  periods  {e.g.  ten  to  fourteen,  even 
sixteen  to  twenty  years) ;  but  these  are  quite  unusual  and  are  pro- 
bably instances  in  which  no  ameliorating  effects  (r.//.  from  treatment) 
came  into  action.  Hutchinson  (Arch.  Surij.,  xi.  78,  1900)  thinks  the 
prolonged  ability  of  the  mother  to  transmit  to  her  offspring  may  be 
due  to  a  storing  up  of  the  syphilitic  virus  in  the  ovaries  and  infection 
of  future  foetuses  by  a  sort  of  telegony.  "  Ova  are  remarkably  retentive 
of  imjnessions,  and  are  perhaps  good  storage  places  for  morbid 
poisons."     Perhaps  they  are. 

In  the  fourth  place,  the  chai-acter  (as  regards  gravity)  of  the 
disease  in  the  transmitter  may  be  supposed  to  have  some  influence 
upon  the  certainty  of  transmission  to  the  unborn  infant.  This  is, 
however,  in  all  probability  a  pure  assumption.  It  has  been  shown 
that  a  very  grave  type  of  sypliilis  in  the  transmitter  may  entail  no 
very  disastrous  effects  upon  the  offspring.  Unfortunately,  alas  !  this 
is  only  one  side  of  the  picture,  for  it  has  also  been  shown  that  the  ex- 
istence of  mild  syphilis  in  the  transmitter  does  not  assume  mildness 
in  the  consequences  which  may  follow  for  the  fcetus  in  utero.  There 
is,  however,  some  evidence  to  support  the  belief  that  the  state  of 
activity  or  quiescence  of  the  syphilitic  manifestations  at  the  time  of 
impregnation  usually  has  a  modifying  eh'ect  upon  the  results  to  the 
unborn  infant. 

In  the. /(/?/<  place,  treatment  very  clearly  and  very  actively  iniln- 
ences  the  results  of  syphilis  as  regards  antenatal  and  inmiediately 
postnatal  life.  In  the  cases  in  which  the  transmission  has  been  by 
both  parents,  anti-syphilitic  treatment,  if  persevered  in,  causes  a  con- 


TREATMENT   OF   FCETAL   SYPHILIS  257 

sideralile  fall  in  infantile  mortality,  and  in  the  cases  in  which  paternal 
transmission  alone  is  supposed  to  be  in  action  the  fall  is  even  more 
marked  (namely,  from  an  infantile  mortality  of  59  per  cent,  to  one  of 
3  per  cent.,  Fournicr).  The  question  whether  the  treatment  is  general 
(through  the  matei-nal  system)  or  local  (vaginal  applications  to  the 
cervix)  may  be  found  to  ha\'e  a  marked  influence  upon  the  degree 
of  good  effected  so  far  as  the  intrauterine  contents  are  interested 
(G.  Eiehl,  irien.  klin.  Wchnschr.,  xiv.  627,  1901). 

Finally,  in  the  sixth  place,  there  can  be  no  reasonable  doubt  that 
these  various  modifying  factors  (age  of  pregnancy,  age  of  disease, 
adoption  of  treatment,  etc.)  may  act  in  some  cases  in  combination, 
and  produce,  on  that  account,  greater  or  less  effects.  It  is  possible, 
also,  that  the  good  effect  of  one  factor  may  simply  neutralise  the  evil 
effect  of  another.  Time  and  treatment,  as  a  rule,  lead  to  attenuation 
of  the  transmission-results. 


Treatment. 

It  will  be  more  convenient  to  take  up  the  treatment  of  antenatal 
syphilis  in  the  chapter  devoted  to  Antenatal  Therapeutics  in  general. 
In  fact,  the  treatment  of  antenatal  syphilis  is  the  key  to  all  antenatal 
treatment ;  it  is,  further,  almost  the  only  instance  of  antenatal  treat- 
ment which  can  be  said  to  have  shown  distinct  successes.  The 
reader,  therefore,  is  asked  to  peruse  at  this  point  the  chapter  on 
Antenatal  Therapeutics  with  which  this  volume  closes. 

I  have  now  endeavoured,  as  best  I  have  been  able,  to  arrange  in 
order  what  is  known  regarding  the  transmitted  diseases  of  the  foetus. 
In  the  immediately  succeeding  chapters  I  shall  have  to  consider  the 
transmitted  toxicological  and  toxinic  states,  and  the  diseases  which  we 
are  compelled  to  call  "  idiopathic."  But,  both  about  the  subjects  which 
have  been  discussed  and  about  those  which  remain  to  be  discussed, 
let  me  say  one  thing — 

"  Little  we  know. 
Mucli  is  to  be  known. 
Hardly  is  it  to  be  learned.'' 


17 


CHAPTER    XV 

Types  of  transmitted  Toxicological  Conditions:  Sources  of  luformation ;  Pi-oblein^ ; 
Lead  Poisoning ;  Mercurial  Poisoning  ;  Pli()S[)horu3  Poisoning  ;  Arsenical 
Poisoning ;  Poisoning  with  Copper  and  Sulpliuric  Acid  ;  Carbonic  Oxide 
and  Coal  Gas  Poisoning  ;  Effects  of  Chloroform  and  Ether  ;  Morphine 
Poisoning  ;  Tobacco  Poisoning  ;  Alcoholism. 

In  the  preceding  chapter  I  have  endeavoured,  not,  I  am  afraid,  with 
great  clearness,  Ijut  with  good  intention  enough,  to  give  an  account 
of  the  diseases  which  may  be  transmitted  from  (or  tlirough)  the 
mother  to  her  unborn  infant,  ilany  of  these  diseases  are  known  to 
be  due  to  microbes ;  all  of  them  are  suspected  to  have  such  origin ; 
and  their  transmission  must  therefore  be  regarded  as  essentially  a 
transjilacental  passage  of  germs  or  of  their  toxins  from  the  maternal 
to  the  foetal  organism.  Further,  it  has  been  shown  that  there  is 
some  measure  of  proof  forthcoming  of  a  reverse  current  of  microbes 
and  toxins  from  fojtus  to  mother,  with  results  for  the  linked  , 
organisms  which  are  not  yet  very  clearly  aseertainal3le,  but  which 
are  doubtless  of  very  considerable  importance.  A  sphere  here  exists 
for  research  of  an  interesting  kind,  pregnant  with  possibilities  both  ' 
pathological  and  therapeutic.  I  have  been  led  also  to  touch  upon  ^ 
the  great  question  of  the  transmission  of  immunity  from  the  one 
linked  organism  to  the  other,  a  problem  of  enormous  magnitude  and 
vast  importance  for  the  single  organism,  how  much  more  for  the  ^ 
intertwined  fceto-maternal  economy  !  Into  this  problem  the  antenatal 
pathologist  is  not  yet  alile  to  enter  fully,  and  can  at  the  most  speculate 
somewhat  vaguely  aliout  possible  anti-bodies,  antitoxins,  and  alexins 
which  may  l^e  produced  in  the  mother  or  in  the  placenta  (?),  and  be  , 
passed  through  the  placental  barriers  to  neutralise  the  lyssins  and  to 
destroy  the  bacteria  in  the  foetus.  The  speculation  may  embrace 
also  a  reverse  current  of  antilyssins  and  microbicidal  ]iriuciples 
from  the  ftetus  and  the  foetal  part  of  the  placenta  to  the  mother. 
With  regard  at  any  rate  to  foetal  typhoid,  it  has  lieen  shown  that  the 
clumping  iirineiple,  the  hypothetical  agglutinin  or  paralysin,  passes 
from  mother  to  fcetus  ;  and,  as  touching  syphiHs,  there  is  some  reason 
to  believe  in  the  action  of  antitoxins  and  alexins  manufactured  in  the 
mother  or  fretus,  and  producing  immunity  in  the  fietus  or  mother., 
Into  this  maze  of  pathogenic  possibilities  and  protective  mechanisms, 
I  have  not,  I  trust,  led  the  reader  too  far ;  I  have  tried  rather  to 
suggest,  tiian  actually  to  put  into  words,  many  of  the  problems  which 
exist  and  which  will  doubtless  in  the  future  come  to  light.  It  will 
be  noticed,  iiowever,  that  the  discussion  has  to  some  degree  passed 
from  microbes  and  bacteria  to  toxins  and  antitoxins ;  and  this  is  a 

258 


FCETAL  TOXICOLOCUCAL   STATKS  259 

circumstance  of  very  considerable  importance,  for  it  means  that  we 
are  approaching  the  purely  chemical  side  of  the  causation  of  disease 
and  health,  and  of  disease-manifestations  and  liealth-phenomena.  It 
need  hardly  be  said  that  we  are  not  in  a  position  to  translate  into 
chemical  symbols  the  composition  of  lyssins  and  alexins  and  such 
vitally  important  compounds;  but  the  tendency  of  investigation  is 
in  that  direction.  It  is  therefore  suitable,  eminently  desirable 
indeed,  that  I  gather  together  in  this  chapter  what  is  known  of  the 
transmission  from  mother  to  foetus  of  the  snljstances  whose  chemical 
composition  is  well  known  and  comparatively  simple.  No  doubt, 
between  the  phenomena  of  the  transplacental  passage  of  the  toxins 
of  disease  and  those  of  the  transmission  of  the  metallic  salts  and 
vegetable  poisons,  there  is,  so  to  say,  a  wide  and  unbridged  river ; 
but  there  is  some  hope  of  a  bridge  being  ultimately  built,  of  at  least 
some  pontoon  arrangement  being  thrown  across,  and  it  will  be  well 
to  anticipate  this  by  constructing  the  indispensable  piers.  Let  us 
then,  in  this  chapter,  prepare  the  j)ier  on  the  chemical  side  of  the 
dividing  river.  Let  us,  in  other  words,  consider  the  transmitted 
toxicological  states  of  the  fcetus. 

Of  many  poisons,  mineral  and  vegetable,  which  might  be  intro- 
duced into  the  maternal  organism  and  pass  over  to  the  foetus,  we 
have  absolutely  no  information,  either  of  a  clinical  kind  from 
observations  on  the  human  subject,  or  of  an  experimental  nature 
from  animals.  With  regard  to  a  few  poisons  we  have  scanty  details, 
both  clinical  and  experimental ;  and  concerning  two  or  three  toxico- 
logical substances  we  have  enough  knowledge  to  warrant  us  in 
making  some  statements.  On  the  whole,  however,  there  is  great 
ignorance  on  a  very  important  matter.  I  may,  for  the  sake  of  clear- 
ness, arrange  this  scanty  information  according  to  its  sources  into 
four  parts.  These  are — (1)  The  clinical  and  post-mortem  evidence 
available  when  a  pregnant  woman  takes,  or  is  given,  accidentally  or 
with  criminal  intent,  one  or  other  of  the  active  poisons,  mineral  or 
vegetable;  (2)  the  information  which  can  be  obtained  from  the 
chronic  poisoning  of  pregnant  women  engaged  in  dangerous  trades  or 
in  an  unhygienic  environment ;  (3)  the  facts  ascertainable  when 
medicines  are  administered  to  the  mother  during  or  just  before  her  con- 
finement; and  (4)  the  results  of  experiments  upon  animals,  when,  for 
instance,  a  poison  is  injected  or  otherwise  introduced  into  the  maternal 
or  fcetal  organism,  and  its  effects  upon  the  fcetus  or  mother  noted. 

With  such  som'ces  of  information  at  command,  I  shall  endeavour 
to  answer  the  following  questions  regarding  certain  poisons  and  their 
effect  upon  the  unborn  infant ;  and  I  shall  condense  as  far  as  possible, 
for,  after  all,  the  facts  are  often  so  scanty  as  scarcely  to  justify 
generalisations.  The  questions  are — (1)  Does  the  poison  pass  the 
placental  barriers  and  reach  the  foetus  ?  (2)  When  it  passes,  is  it  to 
be  found  in  all  parts  of  the  foetus  and  annexa,  or  only  in  special 
organs  ?  (3)  What  changes  does  it  produce  in  the  fretal  tissues  ?  and 
(4)  Does  it  cause  fostal  death,  and  if  so,  by  what  mechanism  is  this 
brought  about  ?  Questions,  these  are,  which  the  reader  will  soon  find 
to  be  more  easily  propounded  than  answered  ! 


2 GO  ANTKNATAI,    I'ATHOI.OCiY   AND    HYGIENE 

It  will  be  convenient  to  consider  first  the  cases  of  poisoning  with 
lead,  mercury,  phosphorus,  arsenic,  and  copper ;  thereafter,  those  due  ' 
to  carbonic  oxide,  chloroform,  and  ether,  and  to  opium,  tobacco,  and 
alcoiiol,  will  be  dealt  with. 

Lead  Poisoning. 

It  has  beeu  shown  by  Porak  {Arch,  dc  mnl.  r.rjidr.  et  d'anat.  path., 
vi.  192,  1894),  by  means  of  experiments  upon  pregnant  guinea- 
pigs,  that  lead  passes  from  the  maternal  into  the  fcetal  body  ;  it  does 
not  seem  to  accumulate  in  the  placenta,  but  passes  at  once  through 
it  to  the  foetus;  having  reached  the  unborn  infant,  it  tends  to  be 
more  widely  difiused  than  in  the  adult,  and  has  beeu  observed  in  the 
skin,  liver,  nervous  centres,  and  elsewhere.  Porak  did  not  find  that 
it  caused  abortion.  J.  Balland  (Gaz.  held,  dc  mM.,  Paris,  xliii.  1141, 
1896),  however,  by  poisoning  guinea-pigs  with  neutral  acetate  of 
lead,  produced  five  abortions  out  of  ten  cases ;  he  did  not  search  for 
lead  in  the  ftetal  tissues.  With  regard  to  the  human  subject,  direct 
evidence  of  the  passage  of  lead  from  mother  to  foetus  is  wanting; 
but  Hermann  Legraiid  and  L.  Winter  (Co)npt.  rend.  Soc.  de  biol., 
Par.,  9  s.,  i.  46,  1889)  found  lead  in  the  liver  of  an  infant,  w^ho  only 
survived  birth  fifteen  days;  in  this  case  both  parents  were  the' 
subjects  of  lead  poisoning.  The  conclusion  that  in  the  human  subject' 
the  existence  of  saturnism  in  the  parents  produces  evil  etiects  upon 
the  foetus  in  utero  is,  however,  founded  not  upon  experiments  upon: 
animals,  but  upon  clinical  observations.  In  order  to  establish  firmly' 
this  conclusion,  ob.servers  in  the  future  would  do  well  to  submit  to 
chemical  analysis  the  abortion-sacs  and  dead-born  foetuses  and 
infants  of  jiarents  known  to  be  suffering  from  plumbism. 

With  regard  to  the  nature  of  the  effects  produced  upon  antenatal 
life,  much  more  is  known.  It  was  in  1860  that  Constantin  Paul 
(Arch.  fihi.  dc  mt'd.,  i.  513,  1860)  made  a  discovery  which  marked  a 
new  era  in  our  knowledge  of  the  relations  existing  between  lead 
poisoning  and  pregnancy.  He  proceeded  from  the  known  fact  that 
syphilis  in  the  parents  may  either  kill  the  foetus  or  produce  syphilis 
in  it ;  and,  from  certain  observations  to  lie  referred  to  innnediately, 
he  came  to  the  conclusion  that,  in  cases  of  lead  poisoning  in  the 
parents,  tlie  offspring  might  be  expected  either  to  perish  in  utero,  or 
to  suffer  after  birth  from  diseases  the  result  of  the  parental 
saturnism.  "  On  comprend  que  c'est  1;\  un  sujet  de  recherches 
excessivement  vaste,  et  qui  exigerait,  pour  etre  complet,  uu  grand 
nombre  d'annees  d'un  travail  assidu."  (True,  Monsieur  Paul!) 
His  observations  were  made  upon  workers  in  type-foundries,  and  hif 
attention  was  drawn  to  the  subject  by  the  following  case  which  he 
studied  in  the  Necker  Hospital.  It  was  that  of  a  woman  who  had 
worked  for  eight  years  in  a  type-foundry,  and  who  was  suffering 
from  metrorrhagia.  Her  history  was  that  she  had  had  tliree  health} 
infants  as  the  result  of  three  normal  pregnancies  before  she  became  i. 
w^orker  in  lead ;  thereafter,  she  had  suffered  several  times  from  leac 
colic,  and  out  of  ten  pregnancies  there  had  lieen  eight  abortions,  one 


LEAD   POISONING    IN   THE   F(ETUS  261 

dead-born  infant,  and  one  child  at  the  full  term,  who  died  at  the  age 
of  five  months.  This  too  striking  fact  ("  ce  fait  trop  frappant")  led 
I'aul  to  make  further  ini|uiries  regarding  other  workers,  women  and 
men,  in  the  same  tuide ;  and,  in  all,  he  collected  eighty-one  observa- 
tions. These  he  arranged  in  six  series,  about  which  I  will  (with  the 
reader's  kind  indulgence)  say  a  few  words. 

In  the  first  group  he  placed  women  who  had  had  more  or  less 
serious  signs  of  plumbism.  There  were  four  women  in  this  series 
who  had  had  fifteen  pregnancies,  of  which  ten  had  ended  in  abortions, 
two  in  premature  labour,  one  in  a  dead-born  infant,  one  in  an  infant 
that  died  in  twenty-four  hours,  and  one  in  an  infant  that  survived 
birth.  In  a  second  group  were  placed  five  women  (including  the 
original  case  referred  to  above),  who  had  had  normal  pregnancies 
prior  to  their  working  in  lead,  but  who  afterwards  out  of  thirty-six 
new  pregnancies  had  had  twenty-six  abortions,  one  premature  labour, 
two  dead-births,  five  infants  of  whom  four  died  in  the  first  year,  and 
two  infants  who  survived.  In  the  third  series  is  a  single  case,  that 
of  a  woman  who  had  ceased  to  work  in  the  type-foundry  ;  as  a  worker 
she  was  five  times  pregnant,  and  had  five  abortions  ;  after  ceasing  to 
work  she  had  one  pregnancy,  the  result  of  which  was  a  living  and 
healthy  infant.  In  the  fourth  series  were  two  cases — (1)  That  of  a 
woman  who  had  ceased  to  work  in  the  foundry,  gave  birth  to  a  living 
infant  four  years  later,  and  had  then  returned  to  work,  and  had 
since  had  one  abortion  and  probably  three  others ;  (2)  that  of  a 
woman  who  had  on  two  occasions  ceased  to  work,  and  in  each 
interval  had  had  a  living  (and  surviving)  infant,  and  who  had  there- 
after worked  continuously  and  had  two  abortions.  The  fifth  series 
was  very  interesting ;  it  contained  seven  cases,  in  which  either  the 
husband  alone  was  exposed  to  lead  poisoning,  or  in  which,  although 
both  parents  were  exposed,  the  husband  alone  suttered  from  signs 
of  saturnism.  Out  of  thirty-two  pregnancies,  there  were  eleven 
abortions  and  one  dead-birth,  while  of  the  twenty  infants  born  alive 
eight  died  in  the  first  year,  four  in  the  second,  five  in  the  third,  and 
three  survived.  The  conclusion  drawn  is  that  the  father  as  well  as 
the  mother  may  transmit  the  evil  effects  of  lead  poisoning,  although 
in  a  less  grave  degree,  to  the  offspring ;  but  to  do  so  he  must  be 
suffering  from  the  lead  ("  en  puissance  de  plomb ")  at  the  time  of 
fecundation.  In  the  sixth  and  final  series  were  the  cases  where  the 
blue  line  on  the  gums  was  the  only  sign  of  plumbism  :  there  were  six 
women  in  this  series,  who  had  twenty-nine  pregnancies,  among  which 
there  were  eight  abortions,  one  premature  labour,  twelve  dead 
infants,  and  eight  living  infants ;  so  that,  when  the  eflects  of  the 
lead  on  the  parent  were  less  marked,  the  results  to  the  offspring 
were  also  less  severe.  Paid  draws  the  evident  conclusion  that,  while 
lead  poisoning  does  not  prevent  fecundation,  it  very  gravely  interferes 
with  antenatal  life ;  for,  out  of  a  total  of  one  hundred  and  twenty- 
three  pregnancies,  in  seventy-three  the  product  was  dead  before 
expulsion  from  the  uterus,  and  thirty-five  infants  born  alive  died  in 
the  first  three  years  of  life.  Manifestly  it  is  a  grave  matter  for  the 
fuetus  when  one  or  both  its  parents  are  "  en  puissance  de  plomb."     In 


2G2     AXTKNATAL  I'ATHOLOCY  ANJ)  HY(;iENE 

a  later  article  {Comjit.  rend.  Soc.  de  hioL,  o  s.,  iii.  4,  1862),  Paul  addrd 
two  other  cases  to  the  list,  giving  a  total  of  one  huiulred  and  forty-uiic 
pregnancies,  ninety-one  abortions,  dead  births,  and  premature  labours, 
and  tliirty-tive  infants  who  died  in  the  first  tiiree  years  of  life. 
Fournier's  exclamation  regardhig  syphilis  is  surely  not  inapplicable 
here  also :  "  Quelles  statistiques!    Quelles  horribles  tables  mortuaires!" 

Paul's  observations  were  so  evidently  important  that  they  at 
once  called  forth  a  leading  article  in  the  Gazette  des  Iwpitaux  (xxxiiL 
225,  1860),  and  stimulated  observers  in  other  countries  to  make 
further  investigations,  lienson  P)aker  {Trans.  Ohst.  Soc.  Lond.,  viii. 
41,  1866),  for  instance,  recorded  three  cases  in  which  lead  j)oisoning 
in  both  parents  was  apparently  the  cause  of  one  or  more  aljortions ; 
but  in  one  instance  there  was  syphilis  also.  Baker  was  of  opinion 
that  the  lead  killed  the  foetus  in  ntero,  and  that  thereafter  and  on 
that  account  abortion  took  place ;  but  he  admitted  that  the  expulsion 
of  the  uterine  contents  might  be  due  to  the  action  of  the  metal  on 
the  uterine  muscle.  Lincoln  {Boston  Mnl.  and  Surg.  Joitrn.,  Ixxxvii. 
306,  1872)  had  an  article  on  "the  influence  of  the  exhalations  from 
fresh  paint  upon  the  ftetus  in  utero."  J.  T.  Arlidge  also,  in  a 
pamphlet  on  The  Diseases  'prevalent  among  Potters  (London,  1872), 
referred  to  the  great  infantile  mortality  in  the  offspring  of  such 
workers  in  lead ;  and  R  Eoque  {Compt.  rend.  Soc.  de  hiol.,  5  s.,  iv.  243, 
1874)  ascribed  to  the  working  in  lead  not  only  the  high  infant  death- 
rate,  but  also  the  frequent  occurrence  of  idiocy,  imbecility,  and 
epilepsy;  in  most  of  Eoque's  sixteen  families  the  father  alone 
suffered  from  plumbism.  Sireday  {Journ.  de  med.  et  cJtir.  prat., 
xlvii.  63,  1876)  and  Ganiayre  {These,  Paris,  1900)  also  considered 
the  relation  of  abortion  and  lead  poisoning :  and  Lefour  {B/'ll.  Soc. 
d'anat.  et  p)hysiol.  de  Bordeaux,  viii.  84,  1887)  dealt  specially  with  the 
father's  influence. 

An  observation,  resembling  in  some  of  its  details  that  made  by 
Eoque,  was  published  by  0.  Itennert  {Arch.  f.  Gynaclc,  xviii.  109, 
1881).  He  found  that  of  the  children  of  eleven  men  wlio  were 
workers  in  pottery-glazing,  many  had  certain  cranial  anomalies.  All 
the  eleven  men  suffered  from  plumbism ;  in  two  instances  the  wives 
were  also  markedly  affected,  and  in  some  other  cases  they  showed 
slight  signs  of  poisoning,  but  some  of  them  were  quite  free.  Either  at 
birth,  or  soon  thereafter,  the  heads  of  the  infants  were  in  many  in- 
stances noted  to  be  S(piare-shaped,  with  very  evident  tubera  frontalia 
et  parietalia ;  they  increased  rapidly  in  size,  but  the  fontanelles  were 
not  hirger  than  usual,  the  sutures  did  not  gape,  and  the  orbits  and 
liosition  of  the  eyeballs  were  normal  (no  hydrocephalus,  therefore). 
There  were  no  signs  of  rickets  in  the  bones  of  the  chest,  linilis,  and  jaws ; 
and  the  other  organs  were  healthy.  These  infants  grew  fairh'  normally, 
neither  their  intelligence  nor  their  general  strength  and  nourishment 
being  affected;  but  they  had  a  very  special  tendency  to  convulsiims 
(tonic  and  clonic  contractions  of  the  back  and  limbs),  and  a  great  num- 
ber of  them  died  (twenty-eight  out  of  fifty-six  who  were  afl'ected,  or 
50  per  cent.).  Most  of  the  macrocephalic  children  suflered  from  com  ul- 
sions,  but  even  the  non-macrocephalic  were  sometimes  affected  in  this 


MKRCURIAL   POISOXINXi    IN   THE   Fd-yrUS  263 

way  :  and  out  of  the  total  number  of  seventy-nine  infants,  fifty-six,  or 
71  per  cent.,  were  affected  either  with  macrocephaly  or  convulsions  or 
both,  but  it  is  to  be  noted  that  six  dead-born  foetuses  are  included 
amongst  the  non-afi'ected.  Eennert  divides  the  cases  into  three  groups  : 
— In  the  first,  both  parents  were  aflected,  and  the  proportion  of  macro- 
cephalics  was  95  per  cent,  (eighteen  out  of  nineteen  cases,  the  remaining 
infant  being  dead-born) ;  in  the  second  group  the  mothers  were  only 
slightly  affected,  and  eighteen  out  of  twenty-seven  cases  (G7  per  cent.) 
were  affected ;  and  in  the  third  group  the  mothers  were  healthy,  and 
twenty  out  of  thirty-three  cases  (61  per  cent.)  were  affected.  In 
Eennert's  cases  the  influence  of  syphilis  and  alcohol  was  apparently 
excluded.  The  localisation  of  the  effects  of  the  lead  upon  the  brain 
and  cranium  is  interesting  when  taken  in  conjunction  with  Porak's 
experimental  results,  in  which  the  metal  was  found  specially  in  the 
nervous  centres.  From  Legrand  and  "Winter's  case  (loc.  cit.),  the 
conclusion,  however,  may  be  drawn  that  lead  tends  to  localise  in  the 
liver  and  spleen ;  it  was  calculated  that  in  the  liver,  which  weighed 
45  grammes,  there  were  from  7  to  8  milligrammes  of  the  metal ;  but 
unfortunately  neither  the  nervous  centres  nor  the  placenta  were 
available  for  analysis.  The  visceral  changes  present  were  of  the 
nature  of  irritative  lesions  of  the  liver  and  kidneys ;  and  in  the 
latter  there  was  also  a  developmental  arrest  in  the  absence  of  the 
zone  of  glomeruli  in  process  of  formation.  It  is  difficult  to  regard 
M.  Anker's  case  {Berl.  klin.  Wchnschr.,  xxxi.  577,  1894)  as  a  genuine 
instance  of  antenatal  transmission,  for  the  child  was  eight  years  old, 
and  may  have  received  the  poison  in  other  ways. 

From  these  scattered  references  to  lead  poisoning  it  is  clearly 
unsafe  to  draw  many  conclusions ;  but  it  may  be  tentatively  suggested 
that  there  is  a  certain  resemblance  between  the  resulting  phenomena 
and  those  found  in  syphilis.  There  is  the  marked  tendency  to 
abortions  and  dead-births  and  to  infantile  multi-mortaUty  ;  there  are 
indications  of  dystrophic  changes,  perhaps  located  specially  in  the 
brain ;  and  there  is  some  evidence  of  peculiar  visceral  lesions  due  to 
the  ii-ritative  effects  of  the  metal  on  the  tissues.  Apparently,  also, 
there  is  paternal  as  well  as  maternal  transmission. 

Mercurial  Poisoning. 

When  a  pregnant  woman  is  the  subject  of  acute  merciu'ial  poison, 
abortion  has  been  known  to  follow ;  but  Wynter  Blyth  {Poisons,  p. 
643,  1895)  referred  to  the  case  of  a  girl  who  swallowed  4i  oz.  by 
weight  of  the  liquid  metal  in  order  to  procure  abortion,  but  without 
any  such  effect,  although  she  suffered  later  from  tremor  and  paralysis. 
It  is,  however,  with  the  effects  of  chronic  mercurial  poisoning  upon 
pregnancy  and  the  foetus  that  we  are  more  directly  concerned.  As 
with  workers  in  lead,  so  with  pregnant  women  employed  in  trades  in 
which  mercury  is  employed,  there  is  evidence  that  the  absorption  of 
the  metal  leads  not  infrequently  to  abortion,  and  that  even  when  the 
infant  is  born  alive  it  may  show  signs  of  poisoning,  e.g.  mercurial 
tremors.     A.  Lize  {Union  med.,  2  s.,  xiii.  106,  1862)  has  found  that. 


2(14  ANIIA'ATAI,    l'Alll()l,()(;V    AND    lIVCilENE 

auiuiij;-  wciiuen  exposetl  to  tlie  fumes  of  nitrate  of  mercury,  pregnane;: 
was  luuUiubtedly  interfered  witli.  Of  twelve  pregnancies  of  womeii 
(not  tliemselves  workers)  who  were  married  to  workers  in  mercurj 
there  were  two  jiremature  laljours,  two  dead -born  infants,  three  chili 
dren  who  died  during  the  first  four  years  of  life,  and  five  childrei 
wlio  survived ;  of  the  five  sui'viving  cliildren,  however,  one  only  wa- 
strong,  and  it  is  noteworthy  tliat,  at  the  time  of  his  conce]ilion,  hi'j 
father  was  not  a  worker.  In  two  cases  both  father  and  mother  war 
exposed  to  the  poison,  and  of  fourteen  })regnancies  which  followec; 
five  ended  in  the  birth  of  dead-born  fcetuses,  and  of  tlie  progeny  c 
tlie  other  nine,  only  three  infants  survived  their  fifth  year.  In  thre 
cases  the  mother  alone  was  exposed ;  there  were  seven  pregnanciei 
three  of  whicli  ended  in  aljovtions,  one  in  a  dead-birth,  and  of  th 
living  infants  one  was  tubercular.  A  curious  observation  is  referre 
to  by  Wynter  IJlyth  {op.  cit.,  p.  G44,  1895) ;  it  was  that  of  a  womai 
twenty  years  of  age,  employed  in  making  barometers,  and  who  suffere 
from  tremor  and  salivation ;  during  a  three  months'  pregnancy  tb 
tremor  ceased,  but  again  appeared  after  she  had  aborted ;  she  agaii 
became  pregnant,  and  the  tremor  ceased  until  after  her  confinement; 

With  regard  to  the  passage  of  mercury  througli  the  placenta  to  th 
fcetus,  Porak  {loc.  cit.)  found  from  experiments  upon  pregnant  guinea* 
pigs  that  the  metal  showed  a  marked  tendency  to  be  stored  up  in  thi 
placenta,  and  that  it  was  not  to  be  discovered  in  the  other  fcete 
organs ;  it  caused  abortion  in  two  cases  out  of  six.  A.  Plottie 
(These,  Geneve,  1897)  found  no  mercury  in  the  placenta,  liquor  amni 
and  fwtus  of  a  guinea-pig  that  had  received  peptonate  of  mercury  il 
the  form  of  subcutaneous  injections ;  but  in  tiie  case  of  a  pregnatj 
rabbit,  that  received  the  mercury  in  tlie  same  form  and  manner,  tkl 
metal  was  found  both  in  the  placentas  and  the  fa?tuses,  but  not  i' 
the  liquor  amnii.  In  the  case  of  the  human  subject,  the  mof 
important  evidence  available  is  got  from  the  cases  of  syphilis  i 
pregnancy  in  which  mercury  has  been  administered.  The  results  d 
the  examination  of  the  fcetus  for  mercury  in  such  cases  are  contaj 
dictory,  but  H.  Cathelineau  and  H.  Stef  {A7i7i.  dc  dcrmat.  et  dc  sypl 
i.  972,  1890;  Bidl.  Soc.  fran^.  dr  dcrmat,  i.  167,  1890)  found  tt 
metal  in  the  placenta,  liquor  amnii,  and  fcetus  in  fi\'e  pregnanci*! 
in  the  human  subject,  and  one  in  tlie  rabbit.  The  mercury  wj 
detected  in  the  liver,  spleen,  heart,  ki«lneys,  meconium,  lungs,  an 
Imxin ;  the  amount  in  the  liver  was  0-00121  gramme  in  10  gramnw 
of  tlie  organ,  or  0-0182  gramme  in  the  whole  viscus ;  the  other  orgai 
named  contained  less.  Strassmanu  (Arch.  f.  Phydol.,  Suppl.  Ban 
s.  95,  1899)  and  D.  Mirto  {Gior.  di  mcd.  leg.,  Lancisiano,  vi.  1,  189J 
have  also  made  observations  on  the  transplacental  ]iassage  of  merciir 

Tlie  following  conclusions  seem  fairly  warrantable.  IMercui 
given  to  the  pregnant  woman  in  the  treatment  of  sy]ihilis  jiasses  i' 
the  foetus,  liquor  amnii,  and  placenta  ;  in  these  circumstances  it  seen 
not  to  cause  but  to  prevent  abortion.  In  non-syphilitic  women,  bov 
ever,  who  have  received  mercury  into  the  sj'stem  in  connection  wil 
their  work,  and  who  are  suH'ering  from  mercurial  poisoning,  tl 
results  would  appear  to  be   abortions,  dead-births,  and  congenit 


PHOSl'llOULS    I'OISONINC;    IN    111]-,   FCKTUS  265 

debility;  but  mercury  does  nut  seem  to  lie  so  fatal  in  these  respects 
as  lead.  In  one  instance  at  least  the  si",nis  of  maternal  ]ioisoning 
largely  disappeared  durinu;  pregnancy  (concentration  of  toxic  action 
upon  the  fietus  or  accumulation  of  the  metal  in  the  placenta  ?). 
Mercury  apparently  passes  to  the  fcrtus  in  the  rabbit  also,  but  not 
in  the  guinea-pig ;  in  the  latter  ease  it  is  stored  up  in  the  placenta, 
and,  therefore,  in  one  sense  reaches  the  fretus,  the  placenta  being 
looked  upon  as  one  of  its  organs.  It  is  not  known  what  changes  the 
mercury  produces  in  the  placenta  and  fo'tal  organs  when  it  reaches 
them. 

Phosphorus  Poisoning. 

That  phosphorus  passes  in  some  form  from  mother  to  foetus  is  proven 
bv  the  presence  of  phosjihates  in  the  latter ;  but  in  what  form  the 
metal  passes  is  not  known  (ride  p.  149).  Nevertheless,  several  ex- 
periments have  lieen  carried  out  to  settle  this  point.  As  far  back  as 
1857,  L.  Eestelli  (Gior.  d.  r.  Accad.  med.-chir.  di  Torino,  2  s.,  xxix. 
257,  o21, 1857)  made  analyses  in  the  case  of  puppies ;  and  much  more 
recently,  L.  IJorri  {Scttimana  mcd.  d.  Spcfimevtalc,  1.  267,  1896),  using 
much  more  exact  methods,  detected  phosphorus  in  the  foetuses  and 
placenta  of  poisoned  rabbits.  Both  observers  obtained  positive 
results,  but  left  the  cj^uestion  of  the  form  in  which  the  metal  passed 
uncertain.  Porak  (loc.  cit.)  got  negative  results  in  the  case  of  guinea- 
pigs. 

There  is  sufficient  evidence,  both  from  the  lower  animals  and  the 
human  subject,  that  in  maternal  phosphorus  poisoning,  lesions  exist 
in  the  fcetus  similar  to  those  found  in  the  mother.  I.  M.  lliura 
{Arch.  f.  path.  Anat.,  9  F.,  vi.  54,  1884)  found  fatty  degeneration  of 
several  of  the  fcctal  organs  along  with  subserous  ecchymoses  in  two 
rabbits  and  two  guinea-pigs  that  had  been  poisoned  with  phosphor- 
ated oil  administered  by  the  mouth.  Pulewka  {I)is>i.,  Konigsb.  i.  Pr., 
1885)  and  S.  Friedliinder  (Diss.,  Konig.sb.  i.  Pr.,  1892)  reported  cases 
of  phosphorus  poisoning  in  pregnancy,  and  the  latter  noted  changes 
in  the  fcetal  organs  (fatty  degeneration).  In  1893,  also,  C.  Seydel 
( Vrtljschr.  f.  gericht.  Mcd.,  3  F.,  vi.  280,  1893)  recorded  a  case  of 
phosphorus  poisoning  in  which  the  victim  gave  birth  to  twins,  dead- 
born  ;  with  the  exception  of  sanguinolent  effusion  into  the  serous 
cavities,  the  fcetuses  showed  no  naked-eye  changes,  but,  on  microscopic 
examination,  extensive  fatty  degeneration  of  the  liver  cells  was  dis- 
covered;  the  kidneys  and  heart  exhibited  no  microscopical  altera- 
tions. G.  Corin  and  G.  Ansiaux  (Vrtljschr.  f.  gericht.  Med.,  3  F.,  vii. 
84,  1894)  carried  out  experiments  upon  dogs ;  one  of  these  was 
pregnant  with  eight  puppies.  The  membranes  were  separated  from 
the  uterine  walls  by  blood  effusion  in  which  small  oil  globules  were 
suspended ;  the  placental  ^•illi  were  much  degenerated,  and  showed 
fatty  streaks ;  the  liquor  amnii  had  a  reddish  colour ;  the  fo'tal  heart 
contained  jjartly  coagulated  blood :  there  was  yellow  fluid  in  the 
pleural  and  peritoneal  cavities,  and  there  were  ecchymoses  on  the 
pleural  and  peritoneal  membranes ;  and  although  the  analysis  of  the 
fcetal  organs  did  not  indicate  the  presence  of  phosphorus,  the  authors 


266  ANri'.NATAI,    I'ATllOI.OCi^'    AND    HVCIF.NK 

couchulud  fioin  Lhu  other  signs  thai  the  poison  had  passed  to  llie 
fcEtuses. 

The  preceding  statements  refer  to  acute  phosphorus  poisoning : 
but  the  question  arises  whether  in  the  chronic  poisoning  associated 
with  certain  trades  any  eHects  upon  pregnancj'  and  the  fcetus  liave 
been  noticed.  According  to  I'alazzi  {Ann.  di  ostct.  c  ijincc,  xxiii.  350, 
1901),  a  case  is  on  record  in  which  for  eight  days  a  pregnant  woman 
took  small  doses  of  phosphorus  causing  subacute  poisoning ;  never- 
theless she  ultimately  recovered,  and  was  delivered  two  months  later 
of  a  living  and  well-formed  infant.  With  regard  to  the  women 
workers  in  match  factories,  the  facts  elicited  by  Korri  were  contra- 
dictory, in  some  factories  abortions  lieing  common,  and  in  others  not 
above  the  average.  Possibly  the  risks  of  serious  results  are  nowadays 
much  lessened  through  improved  hygiene. 

Arsenical  Poisoning. 

There  are  few  observations  regarding  the  ehect  of  either  acute  or 
chronic  arsenical  poisoning  on  antenatal  life.  Keber  ( Vrtljschr.  f. 
rjericM.  u.  off.  Med.  x.xiii.  300,  1863)  records  the  case  of  a  woman, 
pregnant  at  the  fourth  month,  who  poisoned  herself  with  arsenic  in 
the  hope  of  producing  abortion.  After  an  illness  of  two  days  she 
died,  and  apparently  aborted  after  death,  for  a  fcetus  about  5  inches 
long  was  found  lying  at  the  ^"ulva.  On  chemical  examination  no 
trace  of  arsenic  was  discovered  in  the  foetus.  Similarly  in  G. 
Pilomusi-Guelfi's  case  {Gior.  intcrnaz.  d.  sc.  mcd.,  Napoli,  n.s.,  x.  392, 
1888)  no  arsenic  was  detected  in  the  macerated  seven  mouths'  foetus 
of  a  woman  who  had  premature  labour  sixteen  days  after  being 
poisoned.  Keber  {loc.  cit.),  however,  refers  to  a  case  published  in 
1846  in  which  traces  of  arsenic  were  found  in  the  uterus,  placenta, 
and  foetus,  but  not  in  the  liipior  amnii. 

Experimental  evidence  goes  to  prove  that  in  the  guinea-pig  at 
any  rate  arsenic  passes  through  the  placenta  to  the  foetus.  De 
Arcangelis  is  quoted  by  I'alazzi  (Ann.  di  ostct.  c  ginec,  xxiii.  350, 
1901)  as  having  demonstrated  that  the  metal  is  foimd  in  the  fcrtus 
and  in  the  liquor  amnii,  but  in  smaller  amount  in  the  latter ;  the 
quantity  which  passed  was  greater  in  acute  than  in  chronic  poison- 
ing ;  the  passage  was  quick  and  occurred  at  all  dates  iu  pregnancy. 
Porak  {loc.  cit.)  also  found  that  arsenic  passed  (with  difficulty)  to  the 
foetus,  and  that  it  was  there  stored  up  chiefly  in  the  skin ;  a  some- 
what remarkable  observation,  when  the  therapeutic  ettects  of  the 
drug  in  skin  diseases  is  borne  in  mind.  Porak  also  found  it  to  be  a 
powerful  abortifacient  in  the  guinea-pig,  probably  on  account  of  the 
placental  hemorrhages  which  resulted.  In  the  case  of  the  rabbit, 
Plottier  (op.  cit.)  also  got  a  positive  result  as  to  the  pass;vge  of  arsenic. 

Data  regarding  tlie  efi'ect  of  arsenic  on  the  foetal  organs  are  too 
scanty  to  warrant  the  drawing  of  any  conclusions. 

As  to  tlie  intluence  of  poisonin//  vith  copper  upon  antenatal  life, 
next  to  nothing  is  definitely  known.     Of  experimental  evidence  there 


CARBONIC   OXIDE    POISONING  2G7 

is  likewise  little ;  but  I'hilipeaux  {Comjit.  rend.  Soc.  de  hio/.,  7  s.,  i. 
227,  1880)  found  that  by  mixing  basic  acetate  of  copper  with  the 
food  of  a  pregnant  rabbit,  small  quantities  of  it  could  be  detected  in 
the  fcetal  tissues.  Porak  (loc.  cit.)  noted  that,  in  the  case  of  guinea- 
pigs,  the  copper  tended  to  accumulate  in  the  placenta,  liver,  central 
nervous  system,  and  sometimes  in  the  skin  ;  Ijut  he  did  not  observe 
any  abortifacieut  action. 

Casper  (Handbook  of  Forensic  Medicine,  New  Sydenh.  Soc,  ii.  p. 
82,  1862)  records  two  cases  of  poisoning  with  sulphuric  acid  in 
pregnancy ;  in  one  of  these  in  which  the  gestation  was  at  the  fourth 
month,  the  liquor  amnii  had  a  decidedly  acid  reaction  ;  Casper  regrets 
that  in  the  other  this  point  was  not  investigated.  I'alazzi  (loc. 
cit.)  refers  to  a  case  seen  by  Otto  in  which  the  mother  was  poisoned 
with  sulphuric  acid,  and  the  five  months'  fa?tus  had  a  reddish  brown 
skin  as  hard  as  parchment,  with  healthy  internal  organs ;  the  con- 
clusion is  drawn  that  the  acid  can  only  have  reached  the  liquor 
amnii.  This  case  raises,  without  in  a  great  degree  settling,  the 
question  of  the  cause  of  fcetal  death  in  such  forms  of  poisoning  ; 
probably  it  is  in  most  instances  due  to  the  effects  upon  the  mother, 
while  in  a  few  cases  it  may  be  caused  by  the  direct  action  of  the 
poison  on  the  foetus.  To  this  matter,  however,  I  shall  return  under 
the  heading  of  foetal  asphyxia. 

It  will  now  be  well  to  consider  certain  poisonous  gases  and  their 
effects  upon  antenatal  life.  These  are  carbonic  oxide,  chloroform, 
and  ether. 

Poisoning  with  Carbonic  Oxide  or  Coal  Gas. 

Cases  of  carbonic  oxide  and  coal  gas  poisoning  may  be  considered 
together.  Breslau  (Monatsclir.  f.  Gehurtsk.  u.  Frauenkr.,  xiii.  449, 
1859)  narrates  how  two  pregnant  women  were  poisoned  by  inhaling 
coal  gas  (which  contains  carbonic  oxide) ;  one  woman  gave  birth 
twenty-four  hours  later  to  a  recently  dead  foetus  ;  the  other,  who  was 
less  affected  Ijy  the  gas,  had  a  living  infant  some  time  afterwards. 
In  I\I.  B.  Freund's  case  (Monatschr.  f.  Gclnrtsk.  u.  Frauenkr.,  xiv.  31, 
1859)  the  poisoning  was  less  marked,  merely  causing  headache,  but 
five  weeks  later  a  macerated  foetus  was  expelled  from  the  uterus. 
D.  T.  Nelson  (Chiccujo  Med.  Gaz.,  i.  42,  1880)  also  recorded  an 
instance  of  "  coal  gas  poisoning  of  a  foetus  at  term."  F.  Falk 
( Vrtljschr.  f.  gerichtl.  Med.,  n.  F.,  xl.  279,  1884)  gave  interesting 
details  of  a  case  of  carbonic  oxide  poisoning  in  a  woman,  forty-two 
years  of  age,  who  was  in  the  eighth  month  of  her  pregnancy.  Her 
blood  had  the  bright  red  appearance  due  to  this  form  of  poisoning, 
but  the  blood  of  the  female  fcetus  in  utero  had  the  usual  dark  colour, 
and  Falk  concludes  that  the  placenta  does  not  usually  permit 
carbonic  oxide  gas  to  pass  to  the  fcetus.  At  the  same  time  he  refers 
to  a  case  noted  by  Liman,  in  which  both  the  maternal  blood  and  that 
of  a  six  months'  fcetus  showed  the  spectroscopic  appearances  peculiar 
to  carbonic  oxide  poisoning. 


2G8  AXTEXATAL   PATHOLOGY    AND    HYOIEXK 


1 


There  is  also  some  evidence,  derived  from  exjieriments,  bearing 
upon  the  transmission  of  this  <ras  from  mother  to  fo'tus.  A.  Hiigyes 
{Arch./,  d.  ijes.  F/u/siol.,  xv.  :V.M),  1877),  for  instance,  poisoned  two 
rabbits  with  carbonic  oxide  in  from  one  to  one  and  a  half  minutes ;  Ijut 
the  spectroscopic  examination  of  the  foetal  l)lood  gave  negative  results. 
Fehling  {Arch.  f.  Gynaek.,  xi.  523,  1877)  found,  however,  that  if 
rabbits  be  submitted  to  the  effect  of  coal  gas  mixed  with  air  for  a 
longer  time,  the  blood  of  the  fcetuses  sometimes  but  not  always  showed 
traces  of  carbonic  oxide,  but  always  to  a  less  degree  than  did  the 
maternal  blood.  N.  Grchant  and  Quinquaud  (Comjit.  rend.  Acad.  d. 
sc,  Paris,  xcvii.  330,  1883)  exposed  pregnant  dogs  to  the  fumes  for 
thirty-five  minutes,  and  found  the  gas  in  the  blood  of  the  fcetuses, 
but  always  iu  small  quantity.  The  conclusion,  therefore,  seems  to  be 
justified  that,  in  experiments  upon  animals,  carbonic  oxide  does  pass 
in  small  amount  through  the  placenta,  but  that  in  the  case  of  the 
human  subject  the  fcctal  death  is  due  rather  to  the  maternal  asphyxia 
than  to  the  direct  action  of  the  poison.  But,  again,  the  cases  are  too 
few  to  warrant  the  safe  drawing  of  conclusions. 

Chloroform. 

When  chloroform  was  first  introduced  into  obstetrics,  fears  were 
widely  expressed  lest  it  might  injure  the  infant.  How  can  we' 
"  know  or  ascertain  the  possible  consequences  of  the  use  of  such  an 
agent  on  the  Ijrain  of  a  child  ?  And  how  can  we  calculate  what  may 
be  the  ultimate  consequences  of  its  action  in  reference  to  the 
development  of  the  mental  faculties  ?  "  These  questions  were  asked 
in  April  1848 ;  and  in  October  of  the  same  year  Simpson  answered 
them  by  stating  that  out  of  150  infants  born  under  anicstbesia,  all 
except  one  (a  macerated  fcetus)  were  born  alive,  and  that  he  was  not 
aware  that  any  of  them  had  siirce  suffered  from  "cei-ebral  etfusions," 
"  convulsions,"  "  hydrocephalus,"  or  any  other  of  the  "  aii'ections  which 
have  been  prophesied  as  certain  to  befall  all  such  infants  "  {Obstetric 
Works,  ii.  638,  1856).  The  matter  was  also  discussed  in  Germany 
(L.  Meliscber,  Deutsche  Klinik,  iii.  271,  1851).  Of  recent  years  the 
question  has  been  raised  anew  but  iu  a  modified  form,  for  it  has  been 
asked  whether  jaundice  in  the  new-born  infant  might  not  be  due  to 
the  effect  of  chloroform  on  the  foetus.  H.  Fehling  {Arch./.  Gyiiaeh, 
ix.  315,  1876)  found  no  trace  of  any  such  infiuence,  an  experience 
shared  in  to  a  large  extent  l)y  P.  Zweifel  {Arch.f.  Gynaek.,  xii.  252, 
1877);  but  Hofmeyer  {TaycU.  d.  rcrsamml.  dcntsch.  Xaturf.  v.  Aerztc, 
Eisenach,  Iv.  295,  1882),  in  the  case  of  twenty-two  infants,  the 
offspring  of  mothers  who  had  been  chloroformed  in  labour,  found  all 
of  them  more  or  less  icteric  and  showing  albumin  and  tube  casts  in 
the  urine.  In  Hofnieyer's  ciises,  however,  the  labours  were  long  and 
the  amount  of  chloroform  inhaled  considerable  (30  to  100  grammes); 
manifestlv  other  infiuonces  were  at  work  besides  the  chloroform. 
F.  Ahlfeld  {Lchrl.  d.  Gchurtsh.,  201,  1894)  is  inclined  to  think  that 
the  prolonged  use  of  chloroform  in  labour  may  asphyxiate  the  foetus, 
and  bases  his  belief  on  ten  cases  of   Cesarean  section,  in  eight  of 


EFFECT   OF   ETHER   ON   THl'.   FOETUS  2G9 

wliich  meconium  was  found  in  the  liquor  amnii.  Ordinary  everydaj' 
experience,  however,  shows  that  chloroform  given  in  laboiu'  has  little 
or  no  injurious  effect  upon  the  foetus. 

AVith  regard  to  the  experimental  proof  of  the  passage  of  chloroform 
from  the  maternal  to  the  fcetal  blood,  there  is  as  yet  no  aljsolute 
certainty.  P.  Zweifel  {Berl.  Idin.  Wchnschr.,  xi.  245,  1874)  found 
that  the  urine  of  infants  born  to  chloroformed  mothers  had  a 
reducing  effect  upon  Fehling's  alkaline  copper  solution.  In  a  later 
research,  Zweifel  (Arch./.  Gynaeh.,  xii.  238, 1877)  tested  the  placental 
blood  more  accurately,  and  in  six  out  of  seven  cases  noted  quite 
distinctly  the  smell  of  phenyl-carbylamine  (isonitrile),  a  peculiar  and 
penetrating  odour.  Fehling  also  got  positive  results  with  tlie 
carbylamine  test  {Arch.f.  GynacI,:,  xi.  554,  1877).  There  is,  there- 
fore, strong  evidence  in  favour  of  the  lielief  that  chloroform  gas  passes 
into  the  ffftal  blood ;  and,  it  may  be  added,  that  there  is  no  strong 
evidence  that  when  there  it  produces  any  serious  effects. 

Ether. 

Gloomy  forebodings  about  the  effects  of  ether  upon  the  foetus 
in  utero  were  freely  entertained,  just  as  we  have  seen  they  were 
regarding  chloroform.  One  writer  in  1848  (G.  T.  Gream,  Pamphlet, 
1848)  expresses  his  fears  as  follows :  "  It  is  admitted  by  all  that  the 
pulsations  of  the  fcctal  heart  are  greatly  inci-eased  during  inhalation 
— indeed,  to  such  an  extent  has  this  been  noticed,  that  in  some 
instances  the  pulsations  could  not  be  counted,  so  much  were  they 
accelerated.  Are  not  effusions  to  be  feared  from  this  ?  Are  not 
convulsions  after  bii'th  likely  to  ensue  ?  And  may  not  that  occur 
which  would  make  the  most  heartless  mother  shudder  at  the  bare 
possibility  of  herself,  by  want  of  courage,  being  instrumental  in 
producing  ?  May  not  idiocy  supervene  ?  Of  this  we  have  as  yet  no 
experience,  nor  shall  we  have,  perliaps,  for  years ;  but  when  oue  such 
case  occurs,  will  there  be  found  any  one  who  will  afterwards  be 
persuaded  to  submit  herself  to  etherisation  during  pregnancy  ? " 
Fortimately  we  are  often  more  frightened  than  hurt,  and  suffer  often 
more  in  apprehension  than  in  realit}' — Plura  sunt  quw  nos  terrcnt, 
quam  quce  2)remunt ;  ct  scepius  opinionc  quam  re  lahoramus  ! 

As  with  chloroform  so  with  ether,  its  transplacental  passage  to 
the  foetus  has  not  been  absolutely  proven,  although  it  is  extremely 
probable.  To  recapitulate,  there  is  no  reason  to  doubt  the  passage  of 
either  chloroform  or  ether  to  the  fretus,  neither  is  there  any  reason 
to  apprehend  toxic  effects  unless  the  maternal  anaesthesia  be  very 
deep  and  long  continued. 

I  now  pass  to  the  consideration  of  the  action  of  opium,  tobacco, 
and  alcohol  upon  the  unborn  infant. 

Poisoning-  with  Opium. 

The  subject  of  the  possible  poisoning  of  the  foetus  with  opium  is 
chiefly  remarkable  for  the  lengthy  debate,  occupying  three  meetings, 


270  AN'll-.NATAI.    l'ATll()I,()(iV    AND   HYCilKNK 

to  which  it  gave  rise  at  the  Xew  York  Ob.stetriciil  Society  in  1677. 
At  tliese  meetings,  or  as  a  direct  result  of  them,  a  considerable 
amount  of  clinical  e\idence,  of  a  curiously  contradictory  sort,  was 
gathered  together,  mainly  in  reference  to  the  etl'ect  which  mor])hine, 
administered  to  the  mother  during  pregnancy  or  at  laljour,  had  upon 
the  unljorn  infant.  The  discussion  arose  out  of  a  case  of  eclam])sia 
in  the  mother  treated  hy  hypodermic  injection  of  morphine,  witli 
asphy.Kia  and  subsequent  convulsions  in  the  cliild,  the  account  of 
which  was  communicated  by  J.  B.  ]\Iattison  at  the  January  nieetiug 
of  1S77  {Amrr.  Journ.  Ohst.,  x.  299,  1877).  In  all,  one  and  one-third 
grains  of  morphine  were  administered  ;  the  infant  was  asphyxiated  at 
birth,  was  resuscitated  with  difficulty,  and  thereafter  passed  tlirough 
nine  convulsive  seizures ;  lioth  mother  and  child  recovered.  (.)n  the 
motion  of  Paul  F.  MiTudc',  tlie  su])jeet  was  made  the  sjiecial  topic  for 
discussion  at  the  next  meeting  (February  1877),  and  Mundi'  himself 
opened  that  discussion,  which  was  entitled  "The  Iniluence  on  the 
Fcetus  of  Medicines,  particularly  Narcotics,  administered  to  the  mother 
during  pregnancy  and  labour."  He  recorded  a  case  {Aiiter.  Journ.  Ohst., 
X.  300,  1877)  in  which  a  woman  liad  been  taking  from  twelve  to 
sixteen  grains  of  morpliine  daily  during  the  whole  course  of  her 
pregnancy ;  foBtal  movements  were  normal,  and  the  infant  was  bom 
alive  and  apparently  quite  healthy.  Mundi'  suggested  that  there: 
may  have  been  gradual  habituation  of  the  fo'tus  to  the  morphine. 
It  may  be  noted  hei-e  that  Ernest  Kormann  (Dcufsrlic  vied.  Wchnschr., 
iii.  356,  1877)  reported  a  very  similar  case,  in  which  a  truly 
"  morphiophagous  woman,  who  took  from  two  to  four  times  daily  a 
quarter  of  a  hypodermic  syringe-ful  of  morphine — "  Dies  wurde  die 
gauze  Schwangerschaft  hindurcli  fortgesetzt,  imd  trotzdem  erfolgte 
keiue  der  prophezeiheteu  Storungeu " — and  the  fu-tal  movements 
were  in  no  way  almormal,  and  the  infant  was  born  alive  and  liealthy. 
Kormann  concluded  tliat  very  little  or  no  morphine  reached  the  fcetus 
through  the  placenta.  , 

To  return  to  the  discussion  in  the  New  York  Oljstetrical  Society, 
Fordyce  Barker  gave  his  clinical  experience  on  tlie  matter,  and  con- 
cluded that  there  was  no  evidence  which  could  be  accepted  by 
science,  that  narcotic  drugs,  administered  to  the  mother,  ever  pro- 
duced their  specific  effects  on  the  foetus  in  utero.  W.  M.  Chamber- 
lain expressed  similar  views,  founded  upon  the  fact  that  he  had 
reported  a  case  in  which  a  woman  took  during  pregnancy,  labour, 
and  lactation,  twenty  grains  of  morpliine  every  day,  and  tlie  child 
showed  no  ill  efiects.  Peaslee  continued  the  discussion,  exjiressiiig 
very  strong  opinions  on  the  innocuousness  to  the  fwtus  of  opiuiu 
given  to  the  mother ;  he  asked  sarcastically,  "  Does  any  pliysician , 
know  of  a  narcotic  \vhicli,  given  to  the  motlier,  will  even  put  a  fcptus 
asleep  o'  nights,  in  cases  where  the  mother  is  kept  awake  and  in 
distress  1)V  too  forcible  and  continuous  fcvtal  movements?"  W.  K- 
Gillette,  however,  gave  ([uite  a  different  aspect  to  the  discussion :  he 
bro\ight  forward  the  details  of  six  cases,  in  all  of  which  morphine  was 
administered  to  tlie  degree  of  producing  its  physiological  phenomena, 
and  in  all  of  these  instances  the  infant  was  born  in  a  more  or  less 


EFFECT  OF   OPIUM    ON   THE    FQa'L'S  271 

asphyxiated  condition  and  with  contracted  pnpils.  All  the  infants 
save  one  recovered,  and  in  the  one  that  died  intense  cerebral  con- 
gestion was  found.  The  morphine  was  given  in  labour  instead  of  the 
usual  anaesthetics  (chloroform  or  ether).  The  recovery  from  the 
asphyxia  was  quite  unlike  that  in  ordinary  cases  of  apncea  neo- 
natorum. In  two  other  cases,  Gillette  gave  atropine  hypodermically 
to  the  mother  in  the  second  stage  of  labour ;  in  one  of  these  the 
infant's  pupils  were  markedly  dilated.  Skene  believed,  with  Gillette, 
that  morphine,  given  to  the  mother,  would  produce  its  specific  effects 
on  the  fretus.  Thomas  added  notes  of  two  cases  in  which  the  foetal 
heart-beats  seem  to  have  been  slowed  by  morphine. 

The  discussion  closed,  as  so  many  such  discussions  do,  with  the 
expression  of  a  very  decided  difference  of  opinion  among  the  medical 
men  taking  part  in  it ;  but  to  the  reader  at  a  distance  the  impres- 
sions given  are  that  Gillette  and  those  who  agreed  with  him  had  at 
least  some  facts  on  their  side  ;  and  that  morphine,  given  to  the  mother 
to  the  extent  of  producing  specific  efl'ects  upon  her,  produced 
them  also  upon  her  ftetus  in  utero.  It  is  true  that  soon  afterwards 
"\V.  T.  Lusk  {Amcr.  Journ.  Obst.,  x.  413,  1877)  gave  details  of  eleven 
cases  in  which  Gillette's  experiment  was  repeated  ;  only  twice  did  the 
infants  show  asphyxia.  To  this  Gillette  replied  (Amcr.  Journ.  Obst., 
X.  612,  1877)  with  a  second  series  of  fifteen  cases,  in  which  he 
obtained  results  almost  identical  \vith  those  previously  got  by  him- 
self; and  he  attributed  Lusk's  failure  to  obtain  a  similar  efifect  to 
the  fact  that  he  (Lusk)  "  did  not  push  the  drug  to  a  sufficient 
extent  to  produce  even  its  safe  phenomena."  E.  L.  Partidge's 
observations  (Amcr.  Journ.  Obst.,  x.  558,  1877)  went  to  support 
Lusk,  while  J.  J.  Lamadrid's  case  {ibid.,  466,  1877)  added  a  little 
strength  to  Gillette's  opinion.  Thus  the  great  battle  ended  with  a 
splutter  of  fire  on  both  sides  and  a  few  stray  shots  in  the  gathering 
darkness. 

Elsewhere  than  in  New  York  the  effect  of  morphine  on  the  fcetus 
gave  rise  to  discussion.  Fehling  (Arch.  f.  Gynatl:,  ix.  315,  1876) 
thought  that  cases  which  he  had  seen  pro\'ed  that  the  asphyxia 
neonatorum  (with  cereViral  congestion)  which  sometimes  followed 
might  be  ascribed  to  the  morphine.  Ahlfeld  (Lchrbuch,  p.  202,  1894) 
also  met  with  a  case  which  he  regarded  as  one  of  congenital  opiiuu 
poisoning.  Both  he  and  Fehling  regarded  the  negative  results  of 
others  (e.g.,  F.  Benicke,  Ccntrlbl.  f.  Gi/ndk.,  iii.  179,  1879)  as  due  to 
habituation  of  the  foetiis  to  the  effects  of  morphine.  P.  Kubassoff 
(Di.ssc7-t.,  St.  Petersb.,  1879)  also  found  that  opium  produced  distinct 
effects  upon  the  foetus. 

The  actual  presence  of  morphine  in  the  infant  at  birth  was  shown 
by  Bureau  in  1895  (Journ.  de.  mdd.  dc  Par.,  2  s.,  vii.  597,  1895);  the 
mother  took  one  gramme  of  morphine  daily,  the  infant  w'as  born  with 
a  club-foot,  and  morphine  was  found  in  the  blood  of  the  vessels  of  the 
cord  and  placenta.  A.  Plottier  (llihe,  Geneve,  1897),  in  the  case  of 
the  rabbit,  discovered  morphine  in  the  foetuses  and  placentas,  but  got 
doubtful  results  for  the  liquor  amnii :  E.  Marcj^uis  (cited  by  Plottier) 
obtained  similar  results  with  fcetal  kittens. 


272  ANTENATAI,    rATlIOI.OdY    AND    H^XUKNK 

A  curious  piece  of  evidence  which  goes  to  support  the  view  that 
morphine  produces  an  effect  upon  the  fietus  in  utero,  is  supplied  by 
Fere  (Sensation  et  Mouvemcnt,  p.  96,  1900).  He  narrates  the  case  of 
a  pregnant  woman  with  the  morphine  liahit,  who,  when  she  attempted 
to  abstain  from  the  (hnig,  was  so  tormented  liy  excessive  ftetal  move- 
ments that  she  had  to  return  to  the  opium,  whereupon  the  fcetal 
spasms  ceased.  He  had  oliserved  the  same  phenomenon  in  connection 
with  bromide  of  potassium. 

The  general  conclusion  may  therefore  be  drawn,  that  niorpliine 
given  to  the  mother  affects  the  unborn  child,  but  that  while  the  Itahit 
persisted  in  during  pregnancy  seems  to  produce  no  had  elVects  on  the 
fcetus,  the  taking  of  large  doses  at  the  time  of  labour  predisposes  to 
asphyxia  neonatorum.  Tliere  is  no  ground  for  supposing  that  it  leads 
to  abortion  ;  olsviously  such  a  result  is  not  to  be  expected.  There  is, 
however,  room  for  much  more  investigation  here;  and  these  views 
may  require  to  be  modified.     Alas  ! 

Tobacco  Poisoning. 

The  main  question  which  has  arisen  regarding  the  effect  of 
tobacco  poisoning  upon  antenatal  life  is  whether  pregnant  women 
working  in  tobacco  factories  are  more  liable  to  abort  tiian  other 
women.  There  is  again  a  sharp  difference  of  opinion :  for  while 
Decaisne  {Rev.  d'  hyg.,  i.  914,  1879)  and  those  who  took  part  in  the 
discussion  following  the  reading  of  his  paper  (ihid.,  ii.  35,  216,  1880) 
were  quite  convinced  that  abortion  was  very  frequent  in  women 
workers  in  tobacco  in  France,  and  while  T.  Kostial  ( Wehnhl.  d.  I:  k. 
Gcsellseh.  d.  Acrzte  in  Wien.,  viii.  313,  1868)  bore  the  same  testimony 
with  regard  to  Austria,  Ygonin  {Lyun  MM.,  xxxv.  397,  1880)  and 
Piasecki  (^cy.  d'hyrj.,\\\.  910,  1881)  formed  an  opinion  diametrically 
opposed.  The  views  of  Piasecki  and  'Ygonin  have  been  sujiporteil 
recently  by  G.  Etienne  {Ann.  d'  hyg.,  3  s.,  xxxvii.  526,  1897)  with 
regard  at  least  to  the  women  workers  in  the  factories  at  Nancy.  In 
de  Pradel's  case  {Bull,  ct  mem.  Soc.  dc  mdd.  2}rat.  de  Paris,  p.  592, 
1888)  it  cannot  be  proved  that  the  death  of  the  foetus  was  due  to  the 
influence  of  the  tobacco. 

AVhile  there  is  much  doubt,  therefore,  regarding  the  evil  eflect  of 
nicotism  in  cuttiug  short  antenatal  life,  there  seems  to  be  no  shadow 
of  doubt  that  there  is  a  very  large  infantile  mortality  in  postnatal 
life  among  the  offspring  of  women  workers  in  tobacco.  Possibly  this 
may  be  due  in  part  to  the  influence  of  the  milk,  but  it  is  more  pro- 
bable that  it  is  on  account  of  congenital  debility.  Of  course  it  is 
difficult  to  exclude  the  other  possible  causes  of  abortion,  premature 
labour,  and  infantile  mortality  {e.g.  syphilis). 

Alcoholism. 

Eound  the  question  of  the  effect  of  maternal  (and  paternal) 
alcoholism  upon  the  unborn  infaut  there  has  raged  a  fierce  battle,  a 
battle  the  issue  of  which  is  still  in  doubt.     The  arguments  which 


FCETAL   ALCOHOLISM  273 

have  been  advanced  on  both  sides  have  not  always  appealed  solely 
to  the  medical  and  scientific  aspects  of  this  question,  and  doubt- 
less preconceived  notions  have  been  allowed  free  play ;  but  tliere 
have  gradually  emerged  certain  fairly  well  established  facts,  and 
these  I  may  now  consider  under  the  headings  of  experimental  and 
cHiiical. 

With  regard,  in  the  first  place,  to  experimental  evidence,  it  has  to 
be  recorded  that  until  recent  years  no  absolute  proof  was  forthcoming 
that  alcohol  passes  from  the  mother  to  the  foetus.  It  is  true  that 
Plottier  {Thhc,  Geneve,  p.  26, 1897)  found  alcohol  in  the  liquor  amnii, 
foetuses,  and  placenta  of  a  rabbit  into  whose  stomach  he  had  intro- 
duced 15  grammes  of  alcohol  (with  25  grammes  of  water) ;  but 
Palazzi  (Ann.  di  ostet.  e  ginec,  xxiii.  357,  1901)  got  negative  results 
in  the  case  of  a  pregnant  rabbit,  into  whose  subcutaneous  tissue 
iujections  of  20  c.c.  of  ethylic  alcohol  had  been  made.  M.  Nicloux, 
however,  may  be  said  to  have  settled  the  question  of  the  passage  of 
alcohol  from  mother  to  fcetus,  both  for  animals  and  the  human  subject, 
by  a  careful!}-  regulated  series  of  experiments,  the  results  of  which 
were  published  in  1900  (Z'Obstdtriquc,  v.  97,  1900).  By  means  of  a 
somewhat  complicated  but  reliable  appai'atus,  he  was  able  to  ascer- 
tain with  exactness  the  amount  of  alcohol  in  the  blood  and  tissues,  and 
thus  to  introduce  a  new  element  of  certainty  into  his  experiments. 
In  tlie  case  of  six  pregnant  guinea-pigs  he  introduced  from  -h  to  5  c.c. 
(per  kgr.  of  body-weight)  of  absolute  alcohol  into  the  stomach  by  an 
(jesophageal  tube ;  one  hour  later  he  killed  tlie  animal  aud  extracted 
the  fcetuses  from  the  uterus,  and  tested  both  the  maternal  and  the 
foetal  blood  and  tissues  for  alcohol.  He  found  that  alcohol  passed  in 
very  considerable  quantity,  and  that  the  amount  in  the  foetal  blood 
was  relatively  almost  if  not  quite  as  much  as  in  the  material ;  even 
when  the  amount  given  to  the  mother  was  very  small,  it  could 
be  detected  in  the  fcetus.  Nicloux  extended  his  experiments  to 
the  human  subject;  he  gave  to  the  woman  in  labour  about  GO  c.c. 
of  rum  (containing  45  per  cent,  of  absolute  alcohol)  mixed  with 
milk ;  this  was  administered  about  one  hour  before  the  infant 
was  born;  and  in  all  the  cases  (six  in  number)  alcohol  could  be 
easily  detected  in  foetal  blood  from  the  umbilical  cord  and  placenta. 
There  was  no  evidence  of  the  presence  of  aldehyde  or  acetic 
acid,  but  only  of  alcohol.  It  may,  I  think,  be  taken  as  proven 
that  alcohol  passes,  as  alcohol,  from  the  maternal  to  the  foetal 
circulation. 

I  have  now  to  consider  the  experimental  evidence  regardmg  the 
effects  produced  by  alcohol  on  the  foetus.  To  quote  from  Nicloux : 
"  La  realitc  du  passage  de  I'alcool  de  la  mere  au  foetus  demon  tre  la 
possibilite  de  I'intoxication  du  foetus ;  quelle  ne  doit  pas  etre  alors  la 
toxicitii  de  I'alcool  pour  un  organisme  et  surtout  pour  un  systeme 
nerveux  en  voie  de  formation  ? "  Now,  although  it  is  a  priori 
possible,  and  indeed  probable,  that  ill  effects  follow  the  presence  of 
alcohol  in  the  foetal  tissues,  and  more  especially  in  the  central 
nervous  system,  yet  we  must  not  accept  probabilities  as  if  they  were 
proven  facts.     AVhat  then  are  the  facts  ?     M.  Carrara  (Eiv.  di  med. 


274  ANl'I.NAIAl.    1>A1H()1.()(;'>'    AM)    1  lYCill'.NK 

liij.,   Milan,  ii.    177,    1898-'J'.l)  examined    tiie  nerve  centres    of   the 
feetuses  in   two   pregnant  guinea-pigs   that   had   been    treated  with 
alcohol ;  he  noted  the  extraordinary  freshness  of  all  the  tissues  (pre- 
serving j)Ower  of  the  alcohol  ?),  and  observed  that,  in  the  large  cells  of 
the  anterior  horns  of  grey  matter  in  the  spinal  cord,  the  chromophilie 
zones  were  indistinct,  hut  the  nucleus  was  well  marked.     Evidently 
these  observations  were  not  such  as  to  justify  the  drawing  of  con- 
clusions therefrom,  so  I'alazzi  {Ann.  di  ostct.  c  ginc.c,  xxiii.  357,  1901) 
instituted  experiments  upon  fifteen  rablnts  treated  in  such  a  way  as 
to    imitate    chronic  alcoholism  (they  were  injected  liypodermically, 
twice  daily,  with  from  5  to  20  c.c.  of  alcohol) ;  seven  of  these  animals, 
although  mixing  freely  with  the  males,  remained  sterile ;  five  became 
pregnant  and  give  birth  to  living  and  well-formed  ftetuses:  of  the 
twenty-four  fwtuses,  only  one    showed   any  microscopic  anomalies; 
while  neither  the  liver  nor  the  kidneys  had,  so  far  as  Palazzi  had  beeu 
able  to  examine  them,  exhiljited  any  microscoi)ical  alterations.     On 
the  other  hand,  the  experiments  made  by  Fere  {Bull,  et  mhn.  Soc. 
mid.  d.  hop.  de  Paris,  3  s.,  xi.   136,  1894,  etc.),  in   which   various 
kinds   of  alcohol  and  aldehyde   were   injected   into  the  hen's   egg 
in  incubation,  yielded  many  jDOsitive  results  in  the  form  of  non- 
developments,  malformations,  and  monstrosities.     It  may  l)e  added 
that  iVIairet  and  Combemale    {Comjit.  rend.   Acad.   d.    sc,  c^'i.   667,    , 
1888)    noted    that    an    alcoholised    bitch   ga^e    birth   to   deformed 
puppies.      To  these  teratological   results   of  the   action   of  alcohol,    ■ 
attention  will  be  paid  elsewhere  when   I  come   to   deal  with  the    1 
pathology  of  the  embryo.     In  the  meantime,  it  may  be  stated  here    J 
that   experiments   with   alcohol   upon   the   foetuses  of   rabbits  and    j 
guinea  -  pigs   have   given   negative   results  in   so   far  as  structural    i 
lesions  are  concerned.  •' 

Let  us  turn  now,  in  the  second  place,  to  the  clinical  evidence    •■ 
iipon  these  matters.     There  is,  to  begin  with,  a  very  considerable   f 
volume  of  opinion,  with  some  statistics  to  strengthen  it,  that  parental    ' 
inebriety  leads  to  sterility,  to  abortion,  to  premature  labour,  and  tO 
dead-births.     J.  Matthews  Duncan  (Trans.  Edinh.  Ohst.  Sue,  xiii.  113,   • 
1888)  gave  a  useful  summary  of  the  older  evidence  on  tliis  matter,   ; 
adding  some  confirmatory  facts   from   his   own  experience,     ilany 
others  have  written  on  the  same  subject  and  expres.sed  similar  views; 
but  the  contribution  which  W.  C.  Sullivan  {Jonrn.  Mcnt.  Sc,  xlv.  489, 
1899)  made  in  1899  stood  out  from  most  of  the  others  by  reason  of 
its  exactness  and  avoidance  of  fallacies.     He  specially  investigated  ■< 
the  reproductive  history  of  chronic  drunkards  (women)  in  the  Liver- 
pool prison,  and  he  avoided,  as  far  as  possible,  the  cases  which  were  , 
complicated  by  other  degenerative  factors.     He  found  that  of   120  : 
female  inebriates  were  born  600  children,  of  whom  335  (ri5\S  per  cent.)  . 
died  under  two  years  or  were  dead-born,  while  the  remaining  265 
(44-2  per  cent.)  lived  over  two  years.     In  the  case  of  sober  mothers  i 
related  to  the  women  above  mentioned,  the  rate  of  dead-birth  and 
early  infantile  deaths  was  only  23-9  per  cent.     Further,  there  was 
found  to  be  a  progressive  death-rate  in   the  alcoholic  fanrily,  the 
number  of  dead-Ijirths  and  deaths  under  two  yenvn  increasing  as  time 


F(ETAL   ALCOHOLISM 


275 


went  on.     This  fact  is  broiiglit  out  by  one  of  Sullivan's  tables,  which 
I  reproduce  here  : — 


Cases. 

Dead  and 
Dead-born, 
per  cent. 

Dead-born, 
per  cent. 

First-born 

Second-born     

Third-born 

Fourth  and  fifth-born        .... 
Sixth  to  tentli-born 

80 
80 
80 
111 
93 

33-7 
50-0 
52 '6 
65-7 
72-0 

6-2 
11-2 

7-6 
10-8 
17-2 

"  These  figures,"  says  Sullivan,  "  illustrate  very  clearly  the  pro- 
gressively augmenting  character  of  the  influence  of  the  mother's 
alcoholism ;  it  is  specially  noteworthy  that  the  rate  of  still-births 
shows  almost  as  marked  a  tendency  to  regular  increase  as  does  the 
death-rate  among  children  born  alive."  Further,  there  was  a  sensibly 
higher  death-rate  among  the  infants  of  the  mothers  whose  inebriety 
was  developed  at  an  early  period ;  thus,  of  31  women  who  began  to 
drink  at  least  two  years  before  their  first  pregnancy,  118  children  were 
born,  of  whom  74  died  in  infancy  or  were  dead-born  (62-7  per  cent.). 
Sober  2J<^i<:i'nity  seemed  to  have  little  influence,  was  indeed  "  almost 
negligible  " ;  neither  did  an  inebriate  ancestry  appear  to  produce  any 
great  efi'ect.  In  seven  of  Sullivan's  cases  in  which  there  was  con- 
ception in  a  state  of  drunkenness,  in  six  the  children  died  in  convul- 
sions during  the  first  months  of  life,  and  in  the  seventh  case  the  child 
was  still-born.  Amidst  all  this  statistical  gloom  there  was  but  one 
little  bright  light,  one  "  scintilla,"  so  to  say,  or  spark  of  hope, — the 
fact  that  residence  in  prison,  with  of  course  a  stopping  of  all  alcohol, 
often  enabled  an  inebriate  mother  to  give  birth  to  a  living  and  sur- 
viving infant.  For  the  female  habitual  drunkard  it  is  apparently 
the  best  thing  to  be  committed  for  a  term  of  imprisonment  early 
in  her  pregnancy ;  the  prison  baby  may  be  the  best !  A  sad  fact, 
but  a  fact  pregnant  with  hope ! 

It  is  unnecessary  to  dilate  upon  this  aspect  of  the  clinical  effects 
of  maternal  alcoholism ;  but  I  may  here  refer  to  the  results  of  acute 
poisoning  with  alcohol,  a  somewhat  uncommon  accident  in  pregnancy. 
Drappier  {Arch,  dc  (/ym'c.  ct  dc  tocol.,  xxiii.  476,  1896)  has  recorded 
the  case  of  a  lady,  pregnant  for  the  sixth  time,  who  drank  a  litre  of 
brandy ;  she  exhibited  all  the  signs  of  acute  poisoning,  and  died  two 
days  later ;  but  before  death  occurred  she  was  delivered  of  two  dead 
fcetuses  of  an  intrauterine  age  of  six  months.  Drappier  ascribed  the 
premature  delivery  to  an  excessive  amount  of  carbonic  acid  in  the 
uterine  vessels  and  to  death  of  the  foetuses.  How  far  dead-births 
and  abortions  are  due  to  the  direct  effect  of  alcohol,  and  how  far  to 
placental  disease  set  up  by  it,  is  a  question  not  at  present  to  be 
answered.     Facts  are  much  wanted. 


276  ANTl.NATAL   PATHOLOdV    AND    HYGIENE 

Another  nue.stioii  concerned  witli  the  effects  of  alcohol  uijou 
antenatal  life  remains  to  be  considered,  namely,  the  dystrophic  or 
teratological  i-esults.  With  regard,  for  instance,  to  epilepsy  developing 
after  Ijirth,  there  is  a  great  deal  of  evidence  that  pai'ental  alcoholism 
is  an  undoubted  and  powerful  etiological  factor.  Ferii  (Famille 
nhTopalhiijue,  p.  55,  1898),  F.  Combemale  {La  descendance  dcs  alco- 
hoiiqufs,  Montpellier,  1888),  L.  Leter  {These,  Venis,  1892),  Lancereaux 
{Levons  de  cliniquc  malicalc,  p.  59, 1892),  and  many  others  have  written 
on  this  subject;  and  Bourueville  {Proyres  vu'd.,  3  s.,  xiii.  2G2,  1901) 
has  recently  giveu  some  startlmg  statistics.  Of  2554  children  (2072 
boys  and  482  girls)  who  were  admitted  to  the  Bicetre  and  Fondation 
Vallee  between  the  years  1879  and  1900,  all  of  them  suttering  from 
idiocy,  epilepsy,  inil)ecility,  or  hysteria,  1053  were  the  offspring  of 
drunken  parents  (933  had  drunken  fathers,  80  had  drunken  mothers, 
and  40  had  both  parents  drunken).  About  450  of  the.se  children  no 
information  could  be  gathered;  while  1051  had  sober  parents. 
Certainly  235  were  conceived  during  the  drunkenness  of  the  father. 
The  fact  which  emerged  from  these  statistics,  therefore,  was  that 
41-1  per  cent,  of  these  idiot  and  epileptic  children  had  drunken 
parents.  Fere  says  it  is  difficult  to  decide  how  far  we  are  to  blame 
the  alcohol  for  these  results ;  for  they  may  be  due  to  the  primary 
neuropathic  state  which  led  the  parents  to  become  drunkards;  but 
when  we  are  dealing  with  a  vicious  circle  of  causes  and  effects,  it  is 
always  difficult  to  allocate  the  blame  correctly.  SuUivau  {loc.  cit.) 
found  that  out  of  the  219  children  of  alcoholic  mothers  who  lived 
beyond  infancy,  9  or  4'1  per  cent,  became  epileptic,  an  extremely 
high  proportion  as  compared  with  authoritative  estimates  of  the 
frequency  of  epilepsy  in  the  general  mass  of  the  population  (1  io 
6  per  1000).  Other  writers  found  that  from  12  to  15  per  centj 
of  the  surviving  offspring  of  alcoholics  became  epileptic. 

Besides  the  predisposition  to  become  epilejitic  or  imbecile,  the 
children  of  drunken  parents  are,  it  is  stated,  often  malformed.  E. 
Fournier  {Stigmatcs  dijstrophiques  de  I'hMdo-sijphilis,  p.  318, 1898)  has 
\shown  that,  as  with  syphilis,  so  with  alcoholism,  the  progeny  is  apt  to 
exhibit  structural  anomalies,  such  as  iufantilism,  multiple  malforma- 
tions {e.g.  ectrodactyly,  defect  of  occipital  bone,  etc.),  hydrocephaly, 
cranial  asymmetry,  porencephaly,  and  mierocei)haly.  This  statement 
is  simply  the  modern  expression  of  a  belief  as  old  as  the  times  of 
Hippocrates ;  and  the  deformed  Vulcan  was  regarded  as  the  result  of 
Jupiter's  drunkenness.  In  several  of  the  cases  of  foetal  jiathology 
which  I  have  examined  during  the  past  twelve  years,  alcoholism  in 
the  parents  (one  or  both)  has  been  met  with,  e.g.,  in  a  case  of  vesical 
exstrophy,  in  one  of  congenital  heart  disease,  etc.;  but  it  is,  of  cmirse, 
always  very  difficult  to  exclude  all  other  causes  of  malformation,  and 
to  be  sure  that  alcohol  aloue  is  the  etiological  factor.  If  we  follow 
the  same  principles  of  fu'tal  ])athology  which  have  been  laid  down 
already,  we  must  regard  such  dystrophies  as  due  to  the  action  of  the 
poison  upon  the  organism  in  the  embryonic  stage  of  intrauterine  life, 
or  upon  some  part  of  it  which  still  shows  embryonic  characters  while 
in  the  foetal  or  postnatal  period  of  existence. 


i 


FCETAL   ALCOHOLISM  277 

Into  the  question  of  the  hereditary  transmission  of  a  craving  for 
alcohol  I  do  not  propose  here  to  enter,  for  that  falls  to  be  considered 
under  the  pathology  of  the  germ ;  but  it  may  be  said  in  passing  that 
the  children  of  a  drunkard  are  not  necessarily  drunkards,  although  it 
is  probable  that  they  will  show  weakness  in  many  directions,  and  one 
of  these  directions  may  be  a  proneuess  to  alcoholic  excess. 

The  action  of  quinine,  salicylate  of  soda,  cocaine,  etc.,  upon  the 
foetus  will  be  taken  up  more  appropriately  when  antenatal  treatment 
is  considered. 

It  will  be  remembered  that  at  the  beginning  of  this  chapter  it  was 
pointed  out  that  our  knowledge  of  the  transmitted  toxicological  states 
of  the  foetus  was  most  imperfect  and  even  chaotic,  an  opinion  in  which 
the  reader,  I  cannot  doubt,  now  shares.  It  is  therefore  most  unsafe 
to  attempt  to  form  any  general  conclusions  regarding  the  effects  of 
poisons  on  the  unborn  infant.  All  that  may  with  any  assurance  be 
said  is,  that  there  is  experimental  proof  that  some  poisons  reach  the 
fcetus,  and  that  sometimes  these  poisons  produce  structural  altera- 
tions in  the  foetus  and  placenta ;  and  that  clinical  evidence  to  a 
certain  extent  justifies  us  in  asserting  that  a  similar  transmission  and 
similar  effects  may  be  met  with  in  the  human  subject.  Here  is  but  a 
small  scientific  "  scintilla  "  in  a  truly  Egyptian  darkness. 


CHAPTER    XVI 

Ill-defined  Jlorbid  States  of  the  F(etus  :  in  Maternal  Eclampsia  ;  Cancer  ; 
Diabetes  ;  Leukicniia  ;  Heart- Disease,  etc.  ;  Conclusions. 

This  chapter  is  devoted  to  the  consideration  of  certain  ill-defined 
morbid  states  of  the  foetus  in  utero,  which  may  possibly  be  due  to 
toxinic  or  toxic  principles  passing  from  the  maternal  circulation  into 
the  fcetal.  I  have  considered  and  reconsidered  the  advisability  of 
writing  about  these  obscure  morbid  entities  (it  is  not  even  certain 
that  they  are  entities) ;  but  I  have  come  to  the  conclusion  to  do  so  for 
several  reasons,  and  for  two  in  particular.  In  the  first  place,  I 
believe  that  pathological  states  of  the  mother,  such  as  eclampsia, 
jaundice,  cancer,  diabetes,  and  the  like,  do,  in  some  instances,  produce 
morbid  changes  in  the  fa3tus,  and  that  these  changes  are  not  neces- 
sarily of  the  same  nature  as  those  occmi-ing  in  the  mother ;  the  fcetal 
states  are  due  to  the  maternal  maladies,  but  they  are  not  identical  or 
even  similar  in  their  manifestations.  In  the  second  place,  I  believe 
that  these  states  are  of  importance  because  they  bridge  over  the  gulf 
between  the  transmitted  diseases  of  the  foetus  (c.r/.,  variola,  syphilis, 
etc.)  and  the  so-called  idiopathic  maladies  ;  in  the  former,  it  is  (piite 
evident  that  the  mother  transmits  her  own  malady  as  such  to  her 
unborn  infant,  while  in  the  latter  there  is  as  yet  no  evidence  that  the 
foetal  disease  is  due  to  a  maternal  morbid  state.  jMidway  lietween 
these  two  classes  of  diseases  lie  the  ill-defined  patliological  conditions 
of  the  fcjetus  to  which  I  have  referred,  and  which  fall  to  Ije  considered 
in  this  chapter.  Whether  it  is  as  yet  profitable  (in  view  of  the  scanty 
knowledge  we  possess)  to  consider  them  at  all  is  of  course  a  matter 
of  opinion ;  but,  "  deliberando  sa;pe  perit  occasio,"  and,  after  all,  it  is 
but  a  question  of  a  few  pages,  which  the  reader  may  pass  over  if  he 
so  please.  At  the  end  of  the  chapter  an  attempt  will  be  made  to 
give  some  cohesion  to  the  various  statements  which  have  been 
considered. 

Fcetus  in   Maternal  Eclampsia. 

It  has  been  constantly  observed  that  in  cases  of  maternal  albumin- 
uria and  eclampsia  the  chances  of  the  foetus  being  born  alive  aiul 
surviving  birtli  are  very  few.  When  we  attempt  to  go  beyonil  this 
single  observation  we  plunge  at  once  into  a  veritable  jungle  of  theories, 
hypotheses,  isolated  statements,  coincidences,  and  physiological  and 
pathological  assumptions,  among  which  one  may  long  wander  looking 
for  the  light.  It  is  not  possible,  with  our  present  knowledge,  to  find  a 
])athway  right  tlirough  this  jungle,  at  best  we  can  only  hope  here  and 


F(p:tus  in  FXLAMPSIA  279 

there  to  find  traces  of  a  more  or  less  beaten  track  ending  blindly.  Let 
ns  try  to  follow  up  for  a  little  way  one  or  two  of  these  "  blind  alleys." 

We  may  commence  with  the  assumption  that  eclampsia  is  due  to 
retention  of  urea  in  the  blood  of  the  pregnant  woman ;  then,  in  the 
experimental  scientific  mind,  the  suggestion  at  once  arises  that,  by 
injecting  urea  into  a  pregnant  animal,  the  observer  may  be  able  to 
produce  in  the  fwtus  the  same  morbid  changes  as  are  met  with  in  the 
human  fcttus  in  eclampsia  gravidarum.  Accordingly,  A.  Charpentier 
aud  L.  Butte  (A^ouv.  arch,  d'ohst.  et  de  gynic,  ii.  397,  1887)  made  an 
iajection  of  urea  into  the  jugular  vein  of  a  pregnant  rabbit ;  they 
found  urea  in  excess  in  the  tissues  of  the  fcetuses,  and  the  fcetuses 
died  before  the  mother ;  they  concluded  that  the  fcEtal  death  was  due 
to  rapid  accumulation  of  urea  in  the  unborn  infant.  But  evidence  in 
support  of  the  view  that  the  maternal  eclampsia  is  due  to  an  excess 
of  urea  in  the  blood  is  unfortunately  not  forthcoming ;  in  fact,  there  is 
evidence  of  the  opposite  kind,  for  the  blood  of  women  in  eclampsia 
has  been  found  sometimes  to  show  no  excess  of  urea  and  their  urine 
to  show  no  diminution  (or  only  a  very  slight  fall)  in  that  constituent. 
The  physiological  basis  of  the  experimental  work  is  therefore  insecure. 
It  is  not  a  road  likely  to  lead  us  out  of  our  theory-jungle ;  it  is  a  cv.l- 
dc-sac. 

In  another  direction  it  may  be  possible  to  make  some  progress. 
Let  us  examine  the  morbid  anatomy  of  the  foetuses  of  eclamptic  and 
alliuminuric  patients.  The  findings  are  various.  Sometimes  the 
fcetus  dies  in  utero  and  is  born  macerated,  and  then  the  specimen  is 
next  to  worthless  for  pathological  purposes,  for  the  post-mortem 
changes  mask  those  due  to  the  toxins  (if  such  indeed  exist).  Some- 
times the  foetus  is  born  dead,  but  under  circumstances  which  justify 
us  in  stating  that  it  was  the  obstetric  interference  imdertaken  on 
behalf  of  the  mother  that  killed  the  infant.  Again,  the  infant  may  be 
born  prematurely  and  succumb  from  congenital  debility  or  want  of 
the  mother's  milk ;  then  there  will  be  the  histological  peculiarities  of 
prematurity  existing  side  by  side  perhaps  with  those  due  to  the 
maternal  disease.  Again,  the  fcetus  may  be  born  recently  dead  and 
in  a  contracted  state  :  this  may  mean  that  the  infant  has  suffered  like 
his  mother  from  eclampsia  ;  it  may  also  mean  nothing  more  than  rigor 
mortis.  Yet  again,  the  infant  may  be  born  alive,  may  show  albumin 
in  the  urine,  and  may  later  develop  convulsions,  and  then  die ;  but 
albuminuria  of  the  new-born  is  not  uncommon  quite  apart  from  the 
history  of  maternal  eclampsia,  and  convulsions  in  an  infant  are  not,  of 
course,  always  of  renal  origin.  It  is  even  thought  that  the  infants  of 
albuminuric  mothers  may  live,  exhibiting  no  other  peculiarity  than  a 
tendency  to  develop  nephritis  when  attacked  by  scarlet  fever,  etc. 
(Fieux,  Journ.  de  rnkl,  July  25,  1899).  But,  it  may  well  be  asked, 
what  facts  are  there  regarding  the  morbid  anatomy  of  the  fcctus  of 
an  eclamptic  mother  ?  It  may  be  answered  that  such  foetuses  are 
generally  under  weight,  even  if  born  at  the  full  term.  This  fact  I 
have  noted  myself,  more  particularly  in  a  case  which  I  saw  in  con- 
sultation with  Dr.  Robert  Stewart  in  December  1891.  In  that  case, 
also,  there   was  some  atrophy  of  the  liver,  some  congestion  of  the 


280  ANTENATAL    PATI  lOI.OCY   AND    IIVGIKNK 

kidneys,  and  a  con.sideralile  iiieniii;j;i'al  liaiuunliane  ><\vv  the  lefl  siile 
of  the  cerebrum.  It  cannot  be  said,  however,  that  the  internal  changes 
met  with  in  these  foetuses  of  eclamptic  or  allmniinuric  mothers  are  by 
any  means  constant,  far  less  pathognomonic.  Several  observers  iiave 
worked  in  this  field  of  morbid  anatonij-,  and  their  labours  have  been 
summarised  by  E.  Alfieri  (Ann.  di  ostet.  e  fjinec,  xxii.  1077,  1900); 
some  found  lucmorrliages  in  the  kidneys,  in  the  convoluted  or  collect- 
ing tidiules,  or  in  Henle's  loops;  others  found  hii'morrhagic  foci  in 
both  the  liver  and  kidneys ;  others  described  degenerative  clianges  in 
the  renal  epithelium  and  exudations  into  the  glomeruli ;  others  met 
with  blood  effusions  into  the  cranial  cavity  and  the  spinal  canal ;  and 
yet  others  detected  changes  in  the  liver,  such  as  extra-  and  intra- 
lobular dilatation  of  vessels,  atrophic  and  rarely  fatty  degeneration  of 
the  hepatic  cells,  hyaline  thrombi  in  the  blood  vessels,  etc.  Manifestly 
many  of  these  alterations  were  to  lie  regarded  as  the  results  of  trau- 
matism in  labour,  some  of  them  were  possibly  normal,  and  all  of  them 
were  irregular  in  tlieir  occurrence.  Alfieri  (loc.  cit.)  himself  made  a 
painstaking  investigation  of  the  subject,  and  examined  carefully 
twenty-two  fretuses,  five  of  which  came  from  eclamptic  mothers,  ten  of 
which  were  cases  of  asphyxia  neonatorum  due  to  various  causes,  and  thr 
remainder  were  the  offspring  of  mothers  with  albuminuria,  typlioid 
fever,  etc.  In  the  fu:'tuses  born  of  eclamptic  mothers  he  found,  with  a 
certain  degree  of  frequency,  particular  alterations  in  those  organs  which 
are.  usually  affected  in  the  mothers,  namely,  liver,  kidneys,  and  supra- 
renal capsules.  These  altei-ations,  however,  were  not  constant,  nor 
exclusive ;  neither  were  they  characteristic  of  eclampsia.  Further, 
although  it  was  possible  that  they  contributed  to  determine  the  death 
of  the  foetus,  it  was  more  probable  that  they  were  simjily  the  expres- 
sion of  a  particularly  toxic  state,  and  that,  in  certain  instances,  other 
circumstances  (c.ff.  broncho  -  pneumonia,  cerebral  haemorrhage,  etc.) 
might  be  superadded  to  cause  the  fatal  issue.  Similar  changes  were 
found  in  the  fietuses  of  albuminuric  women  who  did  not  develop 
eclampsia  ;  and,  finally,  the  foetuses  from  cases  of  eclampsia  may  show 
no  abnormal  alterations.  Obviously,  in  the  present  state  of  our  know- 
ledge, the  morbid  anatomy  of  these  infants  leads  us  to  no  useful 
conclusion ;  here  is,  then,  another  "  blind  alley." 

Again,  there  has  of  late  been  advanced  a  somewhat  novel  theory 
of  the  origin  of  eclampsia,  to  wit,  the  fwtal  tlieory.  According  to 
this  view,  it  is  not  the  maternal  liver  or  the  maternal  kidneys  that 
are  to  be  l)laraed  for  the  supervention  of  the  convulsions  of  pregnancy, 
but  the  fn'tal  organism  or  its  annexa.  It  is  thought  that  by  the 
reverse  current,  to  which  allusion  has  already  been  made,  toxins  and 
toxinic  products  find  their  way  from  the  foetus  to  the  mother,  and 
produce  in  her  such  a  toxic  condition  that  eclam])sia  supervenes.  The 
theory,  as  thus  stated,  will  hardly  commend  itself :  l)ut  it  is  quite 
possible  that  if  the  mother's  liver  and  kidneys  be  inadequate,  thr 
arrival  from  the  foetus  of  an  extra  (juantity  of  toxinic  products  may 
turn  tiie  scale  already  inclining  towards  the  dreaded  eclampsia.  But 
it  may  quite  well  be  argued  tliat  the  maternal  hepatic  and  renal  in- 
adequacy have  led  to  the  state  of  fcetal  tox;emia,  which  in  its  turn 


FtETUS   IN   ECLAMPSIA  281 

reacts  upon  the  health  of  the  mother.  Here,  tlien,  is  a  vicious  circle 
of  cumulative  cause  and  ett'ect.  No  "  Ijlind  alley  "  in  our  juugle  of 
theories  is  this,  hut  a  wandering  in  a  circle  with  obfuscating  effects. 
For,  when  we  come  to  examine  the  "  foetal "  theory  of  origin  of 
eclampsia  more  closely,  it  is  found  to  rest  upon  a  clinical  observation, 
namely,  the  disappearance  of  the  maternal  alljumiuuria  after  the  intra- 
uterine deatli  of  the  fcetus  ;  but  it  is  now  known  that  foetal  death  is 
by  no  means  constantly  followed  l>y  disappearance  of  the  albumin  in 
the  urine.  In  fact,  E.  Jardine  (Internat.  Climes,  11  s.,  ii.  p.  27,  1901) 
records  two  cases  in  which  the  feetus  was  not  only  dead  but  macerated, 
and  yet  the  urine  contained  albumin,  becoming,  in  one  instance,  nearly 
solid  on  boiling. 

Again,  there  is  the  state  of  the  placenta  in  albuminuria  and 
eclampsia  to  be  considered.  What  effect  may  alterations  in  it 
produce  upon  the  foetus  ?  It  is  well  known  that  placental  haemor- 
rhages are  common  in  cases  of  albuminuria,  and  they  are  met  with 
in  eclampsia,  but  apparently  only  in  the  cases  which  have  been 
preceded  liy  albuminuria.  May  not  the  hiemorrhage  allow  toxinic 
products  to  pass  more  freely  from  mother  to  fcetus  or  from  fcetus  to 
mother,  causing  fcetal  death  and  maternal  eclampsia  ?  It  is  c^uite 
possible.  But  if  the  htemorrhages  be  slight  and  their'  occurrence  in- 
frequent, a  fibroid  condition  of  the  placenta  may  be  produced,  which 
will  prevent  the  free  passage  of  materials  from  mother  to  foetus,  and 
vice  vcrsd  ;  under  such  circumstances  the  fcetus  will  be  unable  to  obtain 
oxygen  or  to  get  rid  of  effete  products,  and  so  will  pass  into  a  state  of 
intrauterine  asphyxia  or  of  intrauterine  uncmia.  Doubtless  there  is 
a  certain  degree  of  truth  in  this  view ;  the  placental  factor  in  these 
ill-defined  morbid  states,  just  as  in  syphilis,  variola,  typhoid  fever,  and 
the  like,  plays  an  important  part.  In  this  direction  progress  will  no 
doubt  ultimately  be  made  ;  in  the  meantime  this  path  also  ends  blindly  ' 

Another  line  of  investigation  has  recently  suggested  itself :  since 
the  effete  products  going  from  fcetus  to  mother  and  viee  vcrsA  must 
pass  through  the  placenta,  that  structure  ought  itself  to  produce 
serious  toxic  effects.  In  order  to  test  this  conclusion,  Palazzi  {Ann.di 
ostet.  e  gincc.,  xxiii.  237,  1901)  carried  out  experiments  on  the  toxicity 
of  the  placenta.  He  made  a  sterilised  infusion  of  the  placentas  of 
five  healthy  women,  and  injected  this  into  the  circulation  of  a 
rabbit.  One  rabbit  died  of  asphyxia,  but  two  other  rabbits  showed 
no  changes.  Further,  the  one  that  died  had  a  very  large  dose 
(2-70  c.c).  The  placenta,  therefore,  is  not  toxic  in  the  ordinary  sense 
of  the  word. 

The  attempt  has  been  made  to  connect  maternal  albuminuria  and 
eclampsia  with  inadequacy  of  the  maternal  thyroid  gland.  M.  Lange 
{Ztsehr.  f.  Gehurtsh.  -ii.  Gyncik.,  xl.  34,  1899)  pointed  out  that  when 
the  normal  pregnancy  -  hypertrophy  of  the  thyroid  was  absent, 
albuminuria  was  very  commonly  present.  Theoretically,  it  may  be 
supposed  that  the  function  of  the  thyroid,  and  possibly  of  the 
parathyroids  also,  is  to  regulate  body-metabolism  and  to  keep  within 
bounds  the  c^uantity  of  toxins  circulating  in  the  blood.  In  pregnancy 
it  is  evident  there  will  be  a  special  need  1  or  such  a  regulating  intiuence ; 


282  ANTKNATAI,    I'ATHOl.CKiV    AM)    IIVCIIKNK 

hence  the  liypertiopliy.  Failing  the  hypertrophy,  toxins  will  accumu- 
late and  will  throw  a  heavy  strain  upon  the  kidneys ;  if  these  organs 
chance  to  be  inadei|uate.  eclampsia  may  follow.  Oliphant  Nicholson 
{Scott.  Med.  and  Surg.  Journ.,  viii.  503,  1901)  has  elaborated  this  view, 
and  has  recommended  and  tested  thyroid  feeding  as  the  line  of  treat- 
ment in  such  cases.  The  matter  is  still  sub  judicc.  It  has  been 
suggested  that  when  the  maternal  thyroid  fails  the  fo'tal  thyroid  may 
take  on  a  greater  activity.  Be  this  as  it  may,  there  can  be  no  doubt 
that  it  will  be  wise  in  future  post-mortems  to  examine  ver}'  carefully 
the  state  of  both  the  maternal  and  fietal  thyroid. 

Foetus  in  Maternal  Cancer. 

When  a  woman  far  advanced  in  cancer  becomes  pregnant,  what, 
it  may  be  asked,  is  likely  to  be  the  state  of  her  unborn  infant  ?  In 
a  case  reported  by  Levaditi  and  Paris  {Journ.  dc  j)hysiol.  et  de  'path, 
gen.,  i.  490,  1899),  the  mother  was  in  a  state  of  marked  cancerous 
cachexia  when  her  child  was  born ;  it  died  in  six  weeks,  and  during 
its  short  life  it  had  a  subnormal  temperature  and  evident  wasting ; 
and  at  death  the  viscera  showed  a  general  streptococcic  infection  with 
a  predominance  of  the  hepatic  lesions.  The  authors  lielie\ed  that 
on  account  of  the  mother's  illness  the  child  was  born  with  its  tissues 
predisposed  to  afford  a  suitable  nidus  for  the  microljes  which  are 
always  present  on  the  skui  and  mucous  membranes,  but  which  are 
not  always  so  virulent  in  their  action.  In  S.  Macvie's  case  {Trans. 
Edinh.  Obst.  Soc.,  xxiv.  130,  1899),  also,  the  infant  died  at  .six  weeks, 
possibly  from  the  same  cause ;  lint  in  this  instance  there  was  pre- 
maturity of  birth  to  be  taken  into  account.  L.  X.  Bourgeois  {Be 
I'injlucnce  dcs  maladies  de  la  femvic  pendant  la  grossesse  sur  la  con- 
stitution et  la  sanUde  I'enfant,  p.  394,  Paris,  1861)  collected  details  of 
eleven  pregnant  women  suffering  from  cancer :  four  gave  birth  pre- 
maturely to  dead-born  infants ;  one  was  confined  at  term  of  an  infant 
that  died  on  account  of  the  necessary  obstetrical  interference ;  tlie 
remaining  six  were  delivered  of  weakly  infants,  three  of  which  suc- 
cumbed to  marasmus,  one  died  of  convulsions,  and  two  survived,  one 
of  whom  showed  signs  of  struma.  Statistics  in  greater  amount  are 
sadly  needed,  bearing  upon  this  important  matter;  in  the  meantime, 
it  may  be  pointed  out  that  lioth  the  maternal  cachexia  and  anamia 
may  have  an  injurious  effect  upon  the  fa>tus  in  utero.  "What  form 
the  maleficent  iufiuence  will  take  we  are  not  at  present  able  to  say. 
It  must  not  be  forgotten  that  the  cancerous  mother  may  have 
children  who  become  cancerous  when  they  become  adults  ;  whether, 
however,  this  tendency  towards  malignancy  is  due  to  the  passage 
of  toxins  from  the  mother  to  the  fietus  in  the  fcetal  and  embryonic 
epochs,  or  to  inherent  peculiarities  in  the  ovum  in  the  germinal 
period  of  antenatal  life,  must  be  left  unanswered,  but  the  latter 
hypothesis  is  more  in  favour  at  the  present  time.  There  is  an  ante- 
natal aspect  of  the  cancer  problem  just  as  there  is  of  Uie  consumption 
question, — an  aspect,  however,  not  at  all  clear  nor  likely  to  be  clear  for 
some  time  to  come;  at  present  the  microbic  or  jiarasitic  theory  has 


FCETUS   IN    DIABETES  "  283 

the  wind  iu  its  sails,  while  the  theoiy  of  the  predisposed  soil  is  fallen 
upon  light  and  variahle  airs,  if  it  Ije  not  altogether  Ijecahned. 

Fcetus  in   Maternal  Diabetes. 

I  have  already  referred  (p.  223)  to  the  snpposition  that  diabetes 
mellitus  might  be  transmitted  as  such  from  mother  to  fcetus ;  of  this 
there  is  no  sufficient  proof,  although  the  recently  reported  observa- 
tion of  Chambrelent  is  strongly  suggestive  {L'Olstetriquc,  vi.  276, 
1901).  It  was  the  case  of  a  4-parous  woman  whose  three  first 
pregnancies  had  ended  in  abortions ;  just  before  the  commencement 
of  her  fourth  pregnancy  it  was  discovered  that  she  was  sufleriug  from 
diabetes  melUtus.  During  the  first  three  months  of  gestation  the 
sugar  diminished  iu  amount,  but  thereafter  it  increased,  attaining  to 
34  grammes  per  litre.  Under  autipyrin  it  fell  to  16  grammes  per 
litre  at  the  time  of  the  confinement.  The  infant  weighed  3600 
grammes,  and  had  to  be  resuscitated ;  its  urine  on  the  eighteenth  day 
of  life  contained  over  2  grammes  of  sugar  per  litre,  but  on  the 
twenty-fifth  day  there  was  no  trace  of  it. 

Apart  from  the  transmission  of  diabetes,  per  sc,  to  the  fcetus, 
there  is  sufficient  evidence  to  show  that  this  disease  in  the  mother 
has  disastrous  consequences  for  the  unborn  infant.  In  1882,  Matthews 
Duncan  ( Trans.  Ohst.  Soc.  LoncL,  xxiv.  256,  1883)  gathered  together 
the  histories  of  twenty-two  pregnancies  in  fifteen  women  suffering 
from  diabetes,  including  personal  observations  (three  in  number)  and 
cases  by  W.  L.  Eeid,  Newman  (2),  John  Williams  (2),  Lecorche,  A. 
Husband,  Bennewitz,  Winckel,  Davidson,  Freriehs,  and  Seegen.  There 
were  four  maternal  deaths.  In  seven  out  of  the  nineteen  pregnancies 
the  child  died  in  antenatal  life  after  having  reached  a  viable  age, 
and  in  two  more  it  succumbed  within  a  few  hours  of  birth.  Hydram- 
nios  was  frequent,  and  in  Husband's  and  probably  in  Eeid's  case 
there  was  sugar  in  the  lic[Uor  amnii.  Some  of  the  dead  infants 
evidently  showed  other  than  mere  macerative  changes ;  for  instance, 
the  child,  a  female,  iu  Bennewitz's  case  weighed  twelve  pounds,  and 
in  one  of  Duncan's  cases  the  infant  was  "  enormous."  In  seven 
pregnancies  in  women  with  diabetes,  reported  by  Lecorche  (Ann.  de 
gynec,  xxiv.  257,  1885),  all  save  one  went  to  the  full  term ;  of  the 
infants,  one  died  in  two  days,  a  second  succumbed  to  hydrocei^haly 
at  the  twenty-first  mouth,  a  third  also  had  hydrocephaly  along  with 
a  double  congenital  hydrocele,  and  two  others  were  very  delicate. 
From  a  larger  number  of  observations,  Ch.  Vinay  {TraiU  des  mcdadies 
de  la  grossessc,  p.  796,  Paris,  1894)  found  that  pregnancy  was  inter- 
rupted in  from  36  to  37  per  cent.,  while  the  infants  died  in  48  per 
cent,  of  the  cases.  The  interruption  of  pregnancy  is  probably  to  be 
accounted  for  by  morbid  changes  iu  the  uterine  mucous  membrane 
(Vinay).  An  interesting  case  was  reported  by  Charrin  and  Delamare 
(Progres  med.,  p.  21,  ii.  for  1901),  in  which  a  woman  suffering  from 
diabetes  was  attacked  with  eclampsia  during  labour ;  the  liver  of  the 
foetus  exhibited  changes  similar  to  those  seen  in  eclampsia,  while  the 
blood  was  like  that  of  diabetic  patients  (red  blood  corpuscles  were 


284  ANTKNATAL   I'A'JHOLOCiV    AND    HYCilENR 

staiiialile  by  iiiagenta  red,  etc.);  tlie  authors  explained  these  foetal] 
changes  on  the  supi)ositioii  that  tlie  special  morbid  agencies  of  both] 
diabetes  and  eclampsia  had  forced  tlie  placental  barriers  and  attacked] 
the  tissues  of  the  unliorn  infant. 

Fcetus  in  Maternal  Leukaemia. 

One  of  the  most  interesting  of  the  pathological  inter-relationshijis 
between  mother  and  fcetus  is  that  met  with  in  maternal  leukicmiu  ni 
leucocythemia.  Apparently  the  leuk;eniic  state  of  the  mother  has 
little  or  no  eflect  upon  the  blood  of  the  foetus.  At  the  same  time  it 
must  be  borne  in  mind  that  very  few  cases  are  on  record  in  which' 
a  woman  sufi'ering  from  leucocythemia  has  become  pregnant — six 
well  described  cases  in  all,  according  to  Yinay  (op.  cii.,  p.  801).  One 
of  the  most  interesting  observations  was  that  made  by  James  C. 
Cameron  {Interned.  Journ.  Med.  Sc,  n.  s.,  xcv.  28,  1888).  The  patient 
had  a  splenic  tumour  during  her  sixth  pregnancy,  but  it  was  while 
she  was  carrying  her  seventh  child  that  she  became  seriously  ill.  At' 
the  seventh  month  of  this  pregnancy  her  red  blood  corpuscles  only 
amounted  to  1,070,000  per  c.mm.,  and  there  was  one  white  for  every 
ten  red ;  she  suffered  greatly  from  dyspnoea  and  attacks  of  epistaxis. 
Premature  labour  occurred,  not  a  drop  of  blood  was  lost,  but  there 
was  the  usual  amount  of  liquor  aninii.  She  recovered.  The  infant, 
a  female,  weighed  -ih  lbs.,  and  measured  ISh  inches  in  length  ;  it  was, 
apparently  strong,  and  throve  nicely  for  the  first  day ;  but  on  the: 
second  day  the  mother  put  it  clandestinely  to  her  breast ;  it  sickened, 
at  once,  developed  a  purpuric  rash,  and  died  on  the  fourth  day.' 
Two  hours  after  birth  the  maternal  and  infantile  bloods  were  as 
follows :  maternal  Ijlood  990,000  red  corpuscles  to  the  c.mm.,  fcetal 
blood  5,210,000;  maternal  blood  1  white  corpuscle  to  4  red,  fa-tal 
blood  1  white  to  175  red.  The  placenta  was  carefully  examined : 
there  was  something  special  in  its  appearance ;  the  blood  in  the, 
sinuses  seemed  thin,  pale,  and  watery,  that  in  the  placental  vessels 
was  of  a  dark  rich  colour,  only  slightly  clotted.  In  the  umbilical 
vein  there  were  4,610,000  red  corpuscles  per  c.mm.,  and  1  white  to 
173  red;  in  the  umbilical  artery  there  were  5,400,000  red  corpuscles 
per  c.mm.,  and  1  white  to  270  red ;  but  in  the  placental  sinuses  there 
were  only  950,000  red  corpuscles  per  c.mm.,  and  1  white  to  ol  red 
(circa).  In  the  foetal  blood  nucleated  red  cells  were  present,  but  not 
in  abnormal  numbers.  The  autopsy  of  the  infant  revealed  nothing 
of  note :  the  thymus  and  thyroid  were  normal,  the  spleen  was  not 
enlarged,  and  the  bone  marrow  was  red  and  abundant  everywhere 
An  interesting  point  in  the  history  of  this  remarkable  case  is  that 
several  of  the  earlier  children  of  this  woman  seem  to  have  been 
leuka-mic,  and  her  mother,  grandmother,  and  brother  seem  to  have 
been  affected  with  the  same  disease.  Obviously,  however,  the  foetuf 
of  the  seventh  pregnancy  was  not  leuk;vmic. 

In  Sanger's  case  (Arch.  f.  Gynaelc,  xxxiii.  171,  1888)  also,  the 
infant,  a  female,  was  born  alive ;  it  showed  no  enlargement  of  the 
spleen    or    liver;    the    lilood    from    the    umliilical  cord  had  norma. 


FCETLS    IN    LKUK.EMIA  285 

characters;  and  six  months  later  the  child  was  tliriving  well  and 
showing  no  indications  of  leukremia.  11.  Paterson  {Edinh.  Med.  Juurn., 
XV.  1073,  1869-70),  in  tln-ee  cases  of  leuka-niia  in  pregnancy  seen  by 
him,  remarked  npon  the  healthy  state  of  the  infants  at  birth.  Some- 
times, however,  the  pregnancy  is  interrupted  (G.  E.  Herman,  Brit. 
il/cf?.  Jouni,,  ii.  for  1901,  p.  1085),  and  then  the  infant  may  succumb. 
Further,  there  is  some  evidence  that  a  toxic  product  may  occasionally 
pass  to  the  fietus  and  cause  its  death  (E.  Kirstem,  Dissertation, 
Konigsberg,  1893).  So  far,  then,  as  our  present  knowledge  carries 
us,  the  leukfemic  mother  does  not  give  birth  to  a  leukaemic  infant. 
This  is  a  fact  of  some  importance,  for  foetal  leuksemia  exists  as  a 
morbid  entity,  and  instances  of  it  have  been  reported  by  Klebs  {Frag, 
nicd.  Wchnschr.,  iii.  489,  509,  1878),  Sanger  (C'entrlU.  f.  Gyniik.,  v. 
371,  511, 1881 ;  Arch./.  Ghjnack.,  xxxiii.  198, 1888),  Siefart  (Monatschr. 
f.  Geburtsh.  u.  Gyncu-k.,  viii.  215,  1898),  and  L.  rollmauu  {Miinclicn. 
Died.  Wchnschr.,  xlv.  44,  1898) :  but  in  none  of  these  was  the  mother 
leukttmic  (in  Sanger's  and  Siefart's  cases  she  had  nephritis,  in 
Pollmann's  she  may  have  suffered  from  an  infectious  process  in 
pregnancy,  and  in  Klebs'  she  seems  to  have  been  quite  healthy). 
It  has  been  rather  hurriedly  concluded  that  proof  is  thus  afforded 
that  leucocytes  cannot  pass  the  placental  barriers ;  but,  as  we  have 
seen  (p.  142),  there  is  evidence  that  the  contrary  is  sometimes  the 
case.  It  may  at  any  rate  be  reasonably  believed  that  morbid  con- 
ditions of  the  maternal  blood  are  not  immediately  reflected  in  the 
state  of  the  foetal ;  and  obser\ations  on  anaemic  pregnant  women 
(p.  139)  support  this  conclusion,  for  in  tliem  the  blood  of  the  unborn 
infant,  although  exhibiting  some  slight  poverty  in  red  cells,  is  by  no 
means  an;emic. 

FcEtus  in  Maternal  Heart  Disease. 

Heart  disease  in  the  mother  is  not  infrequently  productive  of 
premature  labour  and  abortion  ;  sometimes  also  there  is  hjdramnios, 
more  especially  in  the  cases  which  are  complicated  by  albumin- 
uria. According  to  Durozier's  statistics  (Arch,  dc  iocol.,  ii.  577, 1875), 
the  pregnancies  of  forty-one  women  suffering  from  heart  disease 
ended  in  twenty-one  miscarriages  and  dead-births,  in  five  premature 
labours  at  six  months,  and  in  thirty-seven  living  infants  who  died 
before  the  age  of  four  years;  but  these  figures  no  doubt  give  too 
gloomy  an  impression  of  the  effects  of  these  maternal  maladies. 
Vinay  (o/j.  cit.)  met  with  thirty-two  infants,  the  progeny  of  women 
with  heart  disease,  and  the}'  were  nearly  all  born  alive  at  the  full 
term.  The  presence  or  absence  of  cardiac  compensation  must,  of 
course,  markedly  influence  the  results.  Martel  (ThUsc,  Paris,  1896) 
has  endeavoured  to  discover  the  condition  present  in  the  delicate 
infants  of  women  suffering  from  heart  disease,  tubercle,  pneumonia, 
etc.,  and  has  come  to  the  conclusion  that  their  slow  increase  in 
weight  and  frequent  untimely  death  are  due  to  disturbed  cellular 
interchanges  represented  by  an  excessive  excretion  of  urea  (azoturia) ; 
their  cells  do  not  fix  and  retain  the  substances  necessary  for  their 


286  ANTKNATAl.    I'ATIIOI.OOV    AM)    IIVCIKNK 

vegetative  life.  Such  an  infant  "est  un  tiltie  qui  laisse  passer  eu 
graude  partie  les  inaticTes  assimilables."  TIk;  defects  in  assimilation 
in  theii-  turn  are  ])ossibly  due  to  tuxins  which  pass  from  tlic  mother 
to  the  fu'tus,  traversing  the  placenta.  Thus  is  produced  one  of  those 
ill-defined  morbid  states  of  the  fcetus  witli  whicb  tills  cliajjler  deals. 

If  it  were  profitable,  some  space  might  be  given  to  the  considera- 
tion of  the  state  of  the  fu'tus  and  new-born  infant  in  cases  of  maternal 
gout,  osteomalacia,  goitre,  jaundice,  myxa'dema,  and  the  like  ;  but  it  f 
is  not  protitable,  for  the  facts  are  far  too  scanty.     At  the  same  time,  i 
there  is  no  reason  to  doubt  that  progress  will  yet  be  made  in  the  j 
investigation  of  these  matters,  and  that  results  of  value  in  estimating  i 
the  intluence  of  maternal   upon   fecial  conditions  will  ere  long  be  | 
forthcoming.     It  would,  for  instance,  be  of  great  interest  if  we  could  j 
obtain  reliable  oliservations  upon  the  maternal  and  fa'tal  blood  in  i 
one  of  the  rare  cases  in  which  a  hiumophilic  mother  gives  birth  to  a  r 
hiemophilic  infant.     Elsewhere  (126a),  I  refer  at  length  to  a  h;emo-  ; 
philic  woman  who  gave  birth  to  two  h;tmophilic  male  children ;  in 
her  third   pregnancy  she  was  put  under  medicinal  treatment,  and 
gave  birth  to  another  male  infant,  and  in  it  there  were  no  signs  of 
haemophilia.     It  is  difficult  to  know  what  to  say  about  such  cases, 
for  they  are  usually  quoted  as  instances  of  truly  hereditary  diseases 
(i.e.  as  morbid  states  transmitted  from  parents  to  children  prior  to 
conception) ;  but  it  is  just  possible  that  the  maternal  intUience  may  be 
exerted  upon  the  fcetus  during  the  whole  period  of  its  antenatal  life,  ( 
and  that  the  so-called  hereditary  diseases  may  be  in  part  the  result  j 
of  toxinic  activity  going  on  during  the  foetal  epoch.     This  matter,  j 
however,  will  again  fall  to  be  discussed  (vide  Pathology  of  the  Germ).   ! 

Conclusions. 

Can  we  draw  any  conclusions  regarding  tliese  ill-defined  morbid  < 
states  of  the   fcetus  which   are   associated  with   maternal   diseases? 
Any  conclusions  at  any  rate  worth  drawing?     It  is  doubtful;  but  ' 
the  following  cogitations  may  at  least  be  recorded : — 

In  the  first  place,  it  is  quite  evident  that  the   mother  may  be  ' 
seriously  ill  with  diabetes,  cancer,  leuk;emia,  heart  disease,  and  even  ) 
eclampsia,  and  yet  tlie  foetus  be  born  alive  and  apparently  well.     In  ' 
such  instances  the  infant  may  even  survive  birth  and  show  no  weak-  < 
uess  and  no  anonuily  of  assimilation.     At  first  sight,  these  facts  are  ' 
startling,  in  view  of  what  has  been  written  about  the  passages  of 
microbes  and  toxins  from  mother  to  fa?tus :  but  a  little  reflection  will  ' 
serve  to  dispel  some  of  the  surprise.     With  even  the  most  easily 
transmitted  malady  (c.ff.   smallpox),  cases   are   cm   record   in  which 
apparently  no    transmission    took   place ;    and   no  great  stretch  of 
imagination   is   recpiired    to   admit   that    the   same   (or   a   similar) 
mechanism  which  prevents  the  passage  of  the  definite  disease  (e.g. 
smalli)0x)  may  ])revont  also  the  passage  of  the  i)roducts  whicli  set 
up  the  ill-defined  niorliid  state.     I'robalily  it  is  an  easier  matter  to 
save  the  unborn  infant  from  one  form  of  maternal  morbid  infiuence 


CONCLUSIONS  287 

than  from  another ;  but  that  is  a  matter  of  degree  which  does  not 
affect  the  validity  of  the  main  proposition. 

In  the  second  place,  it  is  exceptional  to  find  the  maternal  morbid 
state  {e.g.  gout,  cancer,  eclampsia)  reproduced  as  such  in  the  foetus. 
But,  again,  this  ought  to  e.xcite  no  great  sui'prise,  for  the  conditions 
of  foetal  life  are  not  such  as  to  predispose  to  morbid  changes,  which 
occur  by  choice  in  adult  and  even  in  senile  tissues ;  even  the  new- 
born infant  and  young  child  does  not  take  cancer  and  gont  and 
eclampsia  in  the  same  way  as  its  parents.  Some  ill-defined  morbid 
state  is  just  the  result  which  ought  to  be  looked  for  in  the  fcetus ;  it 
may  be  a  disease,  or  a  malformation,  or  an  anomaly  of  physiological 
reaction,  or  a  predisposition  to  develop  a  disease  differing  from  or 
resembling  that  existing  in  the  parent.  In  a  fatal  case  of  eclampsia 
which  was  under  my  care  in  the  Edinburgh  Maternity  Hospital  in 
April  1901,  the  mother  perished  two  hours  after  delivery,  having  had 
complete  suppression  of  mine  for  several  hours ;  the  foetus,  which 
died  in  birth,  had  a  urinary  bladder  reaching  as  high  as  the  um- 
bilicus, distended  with  limpid  urine.  This  is  but  one  of  many 
illustrations  which  might  be  given  of  the  dissimilarity  of  maternal 
and  foetal  morbid  states.  The  dissimilarity,  hovxver,  does  not  disprove 
a  connection. 

In  the  third  place,  the  commonest  result  in  the  fcetus  of  these 
various  maternal  maladies  probably  is  foetal  death.  The  fatal  issue 
may  be  due  to  the  premature  termination  of  the  pregnancy,  or  it 
may  occur  quite  independently  from  pathological  alterations  in  the 
fcetus,  or  more  commonly  in  the  placenta.  In  the  latter  case,  the 
unborn  infant  is  the  subject  of  an  anto-intoxication,  due  to  the 
accumulation  in  its  tissues  of  carbonic  acid,  and  possibly  of  other 
effete  materials  {vide  Fa?tal  Death).  If  the  cases  of  foetal  death  be 
excluded  from  consideration,  the  majority  of  the  remainder  will  pro- 
bably consist  of  the  infants  born  weakly,  who  lose  weight,  or  at  least 
do  not  gain  any  for  two  or  three  weeks,  and  then  die  either  "  de  rien  " 
or  of  some  intercurrent  disease  which,  under  other  circumstances, 
would  probaljly  be  recovered  from. 

In  the  fourth  place,  it  would  seem  that  in  these  ill-defined  morbid 
states  are  antenatal  conditions  which  it  may  yet  be  found  possible 
to  prevent,  or  to  some  extent  ameliorate,  by  appropriate  antenatal 
treatment.  It  is  not  always  possiljle  to  save  these  infants  after  birth, 
but  might  not  medicinal  treatment  of  the  mother,  prior  to  birth, 
enable  the  placenta  always  to  do  what  it  apparently  sometimes 
spontaneously  does,  namely,  prevent  the  transmission  of  toxins  or 
toxinic  products  to  the  fcetus  ? 


CHAPTER    XVII 

Idiopathic  Diseases  of  the  Fdtus — Typos  :  (jeiieral  Futal  Dropsy- — Definition, 
Clinical  History,  Symptomatology,  Morbid  Anatomy,  Etiology,  Patho- 
genesis, Diagnosis,  Treatment  ;  General  Cystic  Elephantiasis  of  the  Fo-tus — 
Definition,  Clinical  History,  Morbid  Anatomy,  Pathogenesis ;  Congenital 
Elephantiasis — Definition,  Clinical  History,  Syiiiptoiiiatology,  Physical 
Signs,  Pathogenesis,  Treatment ;  Congenital  Myx(uclema  ;  Atrophic  .States 
of  the  Subcutaneous  Tissue. 

The  so-ciillcd  idiopathic  diseases  of  the  foetus  constitute  a  large,  hut, 
as  I  helieve,  a  diminishing  group  of  antenatal  maladies.  As  more 
accurate  knowledge  is  acquired  regarding  these  morhid  states,  there 
can  be  no  doubt  that  one  and  another  of  them  will  finil  their  way 
into  the  groups  of  the  transmitted  diseases,  toxiculogical  conditions, 
and  ill-defined  toxinic  states  with  which  the  last  five  chapters  have 
dealt.  Further,  there  arise  serious  difficulties  of  definition  and 
classification  in  connection  with  this  matter,  for  it  is  almost  imposs- 
ible to  draw  a  hard  and  fast  line  between  transmitted  and  idiopathic 
foetal  states.  For  instance,  we  have  seen  how  a  fcctus  may  be  born 
with  smallpox  upon  it,  although  the  mother  was  free  from  tliat  fever 
during  her  pregnancy.  In  which  group  are  we  to  place  this  case, 
among  the  transmitted  or  the  idiopathic  ?  The  mother,  we  must 
suppose,  transmitted  something  to  the  foetus ;  on  the  other  hand,  the 
foetal  tissues  alone  reacted  in  the  characteristic  manner.  Again, 
there  is  a  large  mass  of  evidence  to  sliow  that  syphilis,  and  possibly 
other  morbid  conditions,  may  arise  in  the  fcetus  through  paternal 
influence  or  through  maternal  influence  prior  to  conception.  Are 
these  to  be  regarded  as  transmitted  ?  They  are  commonly  called 
hereditary.  Are  we  then  to  have  a  third  group  to  contain  the 
hereditary  disease  as  distinct  from  the  transmitted  and  the  idio- 
pathic ?  Is  any  such  separation  possible  ?  I  do  not  think  it  is ;  and 
I  have  elsewhere  {Trans.  Med.-Chir.  Soc.  Edinh.,  n.  s.,  xix.  114,  1900) 
given  reasons  in  support  of  this  contention.  But  it  is  unnecessary 
now  to  enter  into  this  ((uestion ;  I  admit  that  many  of  tlie  idinpathic 
foetal  diseases  may  yet  be  found  to  be  transmitted  either  in  the  post- 
er ante-conceptional  period,  and  it  is  now  my  duty  to  describe  some 
types  of  what  are  still  jirovisionally  regarded  as  idiojiathic  maladies 
of  the  unborn.  I  shall  select  types  in  the  onler  in  which  they  are 
placed  on  page  175. 

General  Dropsy  of  the  Fcetus.  < 

General  dropsy  of  tlie  foetus  was  the  disease  which  in  1887  first 
attracted  my  attention  to  the  study  of  antenatal  pathology  ;  and  since 


GENERAL   F(ETAL   DROPSY  289 

that  year  I  have  had  the  extraordinary  opportunity  of  examining 
eleven  specimens  of  the  malady,  and  have  published  the  results  of 
the  examination  of  several  of  them  ('So,  49,  51,  Gl,  64,  148,  and  161). 
In  my  work,  The  Diseases  of  the  Feet  us,  I  have  de\'oted  eighty  pages 
(vol.  i.  pp.  102-182)  to  the  discussion  of  general  dropsy  of  the  foetus. 
The  result  of  all  these  opportunities  and  of  all  this  writing  is,  that  I 
now  feel  far  less  certain  about  the  pathogenesis  of  the  disease  than  I 
did  shortly  after  I  had  examined  my  first  specimen  !  Of  this,  however, 
I  have  become  increasingly  persuaded :  general  dropsy  of  the  fcetus  is 
not  a  pathological  entity,  but  a  group  of  structural  alterations  due  to 
several  different  causes,  and  really  representing  several  diseases  in 
the  ordinary  sense  of  the  word. 

This  being  so,  it  is  difficult  to  frame  a  satisfactory  definition  of 
general  foetal  dropsy;  but  provisionally  it  may  be  described  as  a 
morbid  condition  of  the  foetus,  characterised  by  general  anasarca,  by 
the  presence  of  fluid  effusions  in  the  peritoneal,  pleural,  and  peri- 
cardial sacs,  and  usually  by  cedema  of  the  placenta,  and  it  results  in 
the  death  of  the  fcetus  or  infant  before,  dm-ing,  or  very  soon  after 
birth.  It  is  the  "  hydropisie  generalisee  du  fcetus  "  of  the  French, 
and  the  "  Haut-und  allgemeine  Wassersucht "  of  the  German  writers, 
and  a  common  international  name  for  it  might  be  found  in  "  hydrops 
universalis  fretus."  The  recorded  cases  date  back  to  the  seventeenth 
century ;  but  it  is  comparatively  rare,  for  I  have  only  l^een  able  to 
gather  together  from  literature  some  seventy  cases  between  the  years 
1614  and  1898.'^  It  is  common,  and  indeed  almost  constant,  to  find 
a  state  of  general  cedema  of  the  grossly  malformed  twin  fcetus 
(acarcUac,  acephalic,  and  acormic),  but  that  is  not  included  among 
the  cases  of  general  foetal  dropsy  properly  so  called. 

The  clinical  history  of  cases  of  this  fcetal  malady  offered  several 
points  of  interest.  The  mother  was  nearly  alwaj'S  well  advanced  in 
her  child-bearing  life,  and  in  only  seven  out  of  sixty-five  cases  was 
her  age  less  than  thirty ;  in  only  one  instance  was  she  primiparous, 
in  all  the  others  she  was  a  multipara,  and  had  generally  had  a  large 
number  of  pregnancies.  For  instance,  in  one  of  the  cases  reported 
by  me  (49)  the  mother  was  thirty-seven  years  of  age,  and  her 
ninth,  tenth,  and  twelfth  gestations  ended  in  the  birth  of  dropsical 
foetuses.  This  character  of  family  prevalence  or  the  repetition  of 
identical  morbid  states  in  successive  infants  of  the  same  parents  has 
l;>een  noted  in  several  of  the  clinical  histories  (cp.  Nachtigaller,  Dissert., 
Berlin,  1896).  The  maternal  health  seems  to  have  been  often  bad; 
but  it  was  generally  of  an  ill-defined  character  ("  delicate,"  "  weakly  "), 
and  in  only  two  or  three  instances  was  any  special  disease,  such  as 
syphilis,  recognised.  The  previous  obstetric  history  was  often  bad 
also;  for  instance,  in  Protheroe  Smith's  case  {Trans.  Ubst.  Soc.  Zand., 
xvii.  30o,  1876)  the  first  child  was  a  healthy  male,  then  came  two 
miscarriages  at  the  third  month,  then  a  healthy  full-time  female,  then 
an  abortion  at  the  sixth  week,  a  full-time  female  that  was  jaundiced 
and  died  in  three  days,  then  a  still-ljorn  female  at  the  twenty-sixth 

'  The  bibliograi)liical  list  will  be  fuund  in  the  Discrisi-'S  of  the  Fa:lu$.  vol.  i.  pp. 
160-16i  ;  and  vol.  ii.  p.  235. 

19 


290  ANTl-AATAI.    I'A  THOI.Od^'    AM)    I  l^(iIKNF, 

week,  tht'U  a  still-ljoni  male  also  at  tlic  twenty-sixth  week,  aiultinallyl 
the  dropsical  fielusat  six  aiiilu  half  months.    The  previous  ])re^nanciej 
generally  ditlereil  very  considerahly  in  tiieir  characters,  hut  agreed  il 
beini|  morbid  in  one  way  or  another  (premature  deliver}',  ahortiori,] 
dead-hirlh,  eon<j;enital  debility  of  infant,  hydrocephalus,  jaundice  ofj 
the  new-born,   etc.).     Sometimes,  but    rarely,  the    paternal  niedicall 
hist(jry  was  referred  to ;  in  Seulen's  case  (Xviie  Ztschrft.  f.  Gcburt& 
ii.  17,  1835)  the  father  suffered  from  jaundice  and  dropsy;  in  Fuhrl 
{Dissc7-t.,  Giessen,  1891)  he  was  an  alcoholic:  and  in  one  of  my  cases 
(49)  he   was  markedly  anicmic.     The  history  of   paternal  syphilis 
is  remarkalile  Ijy  its  aljsence. 

The  si/mptomatolog-i/  of  the  pregnancy  which  ended  in  the  birth  of 
a  dropsical  infant  was  fre(iuently  noteworthy,  ^'ery  often  it  ter- 
minated prematurely  (fourth  month  to  near  the  full  term).  The 
mother's  health  was  seldom  (piite  good,  and  usually  slie  sutl'ered  from 
one  ailment  or  another.  Maternal  dropsy,  limited  or  widespread, 
was  a  comparatively  common  complication.  The  unusually  great 
degree  of  abdominal  distension,  a  condition  <lue  in  part  to  the  large 
size  of  the  foetus  and  placenta  and  in  i)art  to  the  frequently  occurring 
hydramnios,  was  also  often  noted :  and  in  some  cases  there  was  albu- 
minuria, and  in  others  amemia.  Hepatic  derangements,  brouchitis^ 
malaria,  alcoholism,  and  heart  disease  were  met  with,  liut  in  isolated 
instances  as  a  rule ;  and  in  the  great  majority  of  cases  maternal 
syphilis  was  pointedly  excluded.  With  regard  to  foetal  symptomato- 
logy, the  only  recorded  fact  was  the  occasional  statement  that  tht 
foetal  movements  were  feel)le. 

The  lairth  of  a  dropsical  infant  was,  if  near  the  full  term,  a  tediout 
and  often  an  instrumental  matter.  Abnormal  presentations  wert 
unusually  conmion.  The  delay  in  labour  was  sometimes  overcome  b} 
the  natural  efforts  and  sometimes  by  manual  or  instrumental  traction 
but  in  certain  instances  the  procedures  which  were  finally  adoptee 
before  birth  (in  fragments)  was  effected,  reached  the  utmost  limits  o 
embryulcia,  evisceration,  disruption,  and  dilaceration.  In  some  casei 
the  medical  attendant  seems  to  have  lost  all  nerve,  as  first  one  liml 
and  then  another,  and  then  a  fragment  of  the  trunk  or  the  head,  wa; 
dragged  to  light  from  the  maternal  passages.  When,  howevei',  thi 
foetal  abdomen,  lieing  within  reach,  was  tapped,  it  was  seldom  foimi 
necessary  to  resort  to  such  endiryoclastic  procedures.  The  third  stagi 
of  labour  was  often  rendered  somewhat  difficult  on  account  of  tin 
large  size  and  dropsical  state  of  the  placenta,  and  l>y  reason  of  uterini 
inertia  due  to  delay  in  the  earlier  stages.  The  puer])eria,  it  is  note 
worthy,  were  generally  quite  normal ;  in  fact,  the  rapid  disappearauc 
of  many  of  the  maternal  symptoms,  immediately  after  the  emptyin; 
of  the  uterus,  suggested  the  conclusion  that  the  fn^tal  condition  wa 
often  the  cause  rather  than  the  result  of  the  mother's  ill-health. 

The  postnatal  clinical  history  of  the  dropsical  infant  was  chief!, 
remarkable  for  its  abbreviation.  Often  the  foetus  escaped  antenata 
only  to  meet  intranatal  death,  and  if,  by  any  chance,  he  came  into  th 
world  alive,  it  was  seldom  that  the  lungs  could  act  pro])erly,  o 
account  of  the  fluid  accumulations  in  the  thorax  and  abdomen.     I 


GENERAL   F(ETAL   DROPSY 


291 


Fio.  30. 
Vertical  Mesial  Sectiou  of  Fojtus  witli  General  Dropsy,  left  face  shown,  (i  natural  size.) 
«,  Anterior  fontanelle  ;  h,  (Edematous  scalji  tissue  ;  c,  H»morrliage  in  falx  cerebri ; 
d,  Posterior  fontanelle  ;  c,  Cerebellum  ;  /,  Pituitary  body  ;  g,  Basi-occiput ;  h,  Pos- 
terior arcli  of  atlas ;  i,  First  dorsal  vertebra  ;  j,  Thynnis  gland ;  k,  Fluid  in 
pericardium  ;  I,  Liver ;  m,  Pancreas  ;  »,  Pylorus  ;  o.  Fluid  in  peritoneum  ;  p.  First 
sacral  vertebra  ;  q.  Umbilical  cord  ;  r,  Tunica  vaginalis  testis  ;  s,  Penis  ;  t,  Trachea. 


292  ANTKNATAL    l'ATII01,0(iV    AND    HVCilENK 

one  case  (Seeger,  Miscell.  Acad.  nat.  curios.,  Dec.  i.,  Aim.  \.,\i.  Kll', 
1670),  however,  life  lasted  a  few  clays,  aud  for  a  few  hours  in  a  few 
otlier  instances  ;  but  generally  the  potential  mortality  of  this  intra- 
uterine malady  became  real  at  birth.  Stat  sua  ctiiquc  dies!  "Water- 
babies  "  these  are,  with  a  lirief  tenure  <jf  life ! 

The  study  of  the  morbid  anatomy  of  the  recorded  instances  of 
general  fojtal  dropsy  reveals  sonic  alterations  conimnn  tn  all  the  cases 
and  .some  peculiar  to  one  or  two.  I  believe  that  I  was  the  first  (in 
1887)  to  study  the  pathology  of  this  fostal  malady  by  means  of  frozen 
sections,  a  method  which  materially  assisted  in  clearing  up  certain 
doubtful  points.  The  appearances  presented  by  one  of  the  slaljs  (the 
left)  (if  a  vei'tical  mesial  .section  are  sliown  in  Fig.  ;]0. 

Tlie  weight  and  measurements  of  the  foetus  were  not  often  recorded; 
l)ut,  wlien  they  were  noted,  they  were  always  larger  than  they  ought 
to  have  been  for  the  jieriod  of  antenatal  life  arrived  at.  The  abdomen 
especially  was  apt  to  have  a  greatly  increased  circumference.  A 
general  dropsical  state  of  the  subcutaneous  tissue  was  the  most 
evident  and  most  constant  macroscopic  condition,  and  it  was  noted  in 
all  tlie  recorded  cases.  It  was  sometimes  stated  that  certain  i)arts  of 
the  body  were  specially  dropsical,  e.g.  the  scalp,  the  face,  the  abdomen, 
the  limbs ;  but  sometimes  there  was  an  equally  ditl'used  oedema. 
Usually  the  efl'usion  was  serous  in  type,  but  sometimes  it  resembled 
partly  congealed  gelatin,  a  condition  possibly  due  to  the  undeveloped 
or  mucoid  state  of  the  subcutaneous  tissue  when  attacked  l>y  the 
oedema.  The  fluid  oozed  freely  from  superficial  cuts  or  tears  in  the 
integument,  and  I  have  several  times  noted  that  if  a  fcEtus  showing 
this  disease  were  left  overnight  on  a  ])late,  its  bulk  was  greatly 
reduced  in  the  morning.  Virchow  {Arch.  f.  jxith.  Anat.,  xxii.  426, 
1861)  found  albumin,  but  no  sugar,  in  this  fluid  in  one  case.  The 
subcutaneous  oedema  may  sometimes  be  so  great  as  to  cause  great 
deformity,  as  a  glance  at  Fig.  31  (which  represents  the  head  of  a 
dropsical  fo?tus  examined  by  me  in  ]May  189."'>  (61),  which  had  occurred 
in  the  practice  of  Dr.  F.  W.  Mann  of  Ashton-under-Lyne)  will  im- 
mediately and  convincingly  pro\e.  The  skin  has  a  dusky  red,  livid, 
coppeiy,  or  sometimes  a  pink  colour.  There  is  great  friability  of  the 
tissues,  particularly  of  the  subcutaneous  but  also  sometimes  of  the 
muscular  and  osseous.  It  is  to  this  character  that  we  must  ascribe 
the  piecemeal  extraction  of  the  foetus  which  has  occasionally  been  so 
grajjlucally  described  by  obstetricians. 

In  the  great  majority  of  the  reported  cases  the  presence  of  tluid 
in  the  pleural,  pericai'dial,  and  peritoneal  cavities  was  noted  (Fig.  oO). 
The  presence  of  Huid  in  the  alxlomen  was  a  very  constant  feature ; 
and  the  effusion  was  described  as  clear,  sti-aw-yellow,  brownish 
yellow,  olive-green,  clear  gi-een,  citron,  or  lirownish  in  colour,  aud 
transparent  in  character.  Sometimes  flakes  of  lymph  were  found 
floating  in  it ;  sometimes  it  was  albuminous ;  and  in  one  of  my  cases 
there  was  some  liile  pigment  and  a  very  small  proportion  of  proteids. 
Hydrothorax  and  hydropericardium  were  also  very  common ;  and  iu 
a  few  instances  hydrocele  and  hydrocephalus  existed.  The  appear- 
ances presented  by  the  viscera  were  far  from  uniform,  and  indeed 


GEXERAL   F(KTAL    DROl'SY  293 

varied  within  wide  liiuits;  but  the  most  fi-e(jueiitly  recorded  char- 
acter was  a  general  bloodlessness  (t'.//.,  of  the  liver,  brain,  heart,  and 
thvmus).  Furtlier,  in  a  few  cases,  disease  or  malformation  of  the 
heart  was  noted ;  in  Virchow's  case  (loc.  cit.)  there  was  transposition 
of  the  great  vessels,  defect  in  the  interventricular  septum,  and  signs 
of  fcetal  endocarditis;  in  Lawson  Tait's  {Trans.  Ohst.  Soc.  Load.,  xvii. 
307,  1876)  there  was  a  closed  state  of  the  foramen  ovale  with 
wide  patency  of  the  ductus  arteriosus  ;  and  in  E.  Pott's  (Jahrb.  f. 
Kindcrhlk.,  xiii.  11,  1879)  there  was  persistence  and  stenosis  of  the 
truncus  arteriosus  communis.  A  diaphragmatic  hernia,  leading,  it 
was  supposed,  to  compression  of  the  inferior  vena  cava,  was  noted  by 


Fic.  31.— Gi'iieral  Dropsy  of  the  Fiftiis. 

C.  Behm  {Ztschr.f.  GeburtsJi.  u.  Gyndk.,  ix.  197,  1883).  Signs  of  peri- 
tonitis w^ere  found  in  six  cases  (out  of  sixty-five) :  it  was  therefore 
relatively  uncommon,  for  the  presence  of  fluid  in  the  peritoneal 
cavity  could  not  of  itself  be  taken  to  imply  inflammation.  The  liver 
had  no  constant  appearances  ("  large,"  "small,"  "  anicmic,"  "congested," 
"  soft  and  friable,"  "  firm  and  cirrhotic  ") ;  and  the  spleen  varied  in 
much  the  same  way.  In  some  cases  the  kidneys  appeared  normal  to 
the  naked  eye,  in  others  they  were  finely  granular,  in  others  they 
were  the  seat  of  cystic  degeneration,  and  in  others  they  were  small, 
soft,  and  pale  ;  but  in  most  of  the  records  no  description  at  all  is  given 
of  them.  The  intestines  were  generally  small,  contracted,  and  wnth  a 
short  mesentery.  There  was  a  uterus  septus  with  vagina  duplex  in  one 
of  E.  HiJnck's  dropsical  fcstuses  (Dissert.,  Kiel,  1887) ;  and  in  a  few 
cases  it  was  noted  that  the  bones  were  friable.  "t!""!-^" 

In  very  few  instances  was  there  any  record  of  the  microscopic 


294  ANTKNATAl.    I'ATHOLCXiY    AND    HYGIENE 

appearances  of  the  tissues.  In  one  ease,  that  repnrtcd  1)}- E.  Schutz 
{Frag.  ined.  Wchnschr.,  iii.  449,  1S7>S),  there  existed  the  histoloj^ii nl 
clianges  in  the  vessels  and  organs  wliich  are  usually  regarded  as 
characteristic  of  fuctal  syphilis;  and  the  mother  also  showed  signs 
of  syphilis.  In  a  few  cases  a  leuka-mic  or  leuka-nioid  conditicm 
was  discovered,  ami  in  my  own  cases  (49)  there  was  some  incUcn- 
tiou  of  this.  There  was  an  excess  of  white  corpuscles  in  the  blo'l 
and  in  all  tl)e  organs,  but  especially  in  tlie  kidneys  there  wtiv 
numerous  accumulations  of  leucocytes.  .Sanger  (./I rcA.  y'.  GynmL., 
xxxiii.  198,  1888)  considered  that  the  instance  of  fct'tal  dro^JSy  seiii 
by  him  was  really  of  the  nature  of  congenital  splenic  or  spleiin- 
myelogenous  leukiemia.  It  is  doubtful  whether  the  few  details 
available  concerning  the  microscopical  appearances  in  general  anasarca 
of  the  fcEtus  are  sufficient  to  warrant  any  conclusions  being  di'awn  : 
further  researcli  is  imperatively  demanded  in  tliis  direction. 

The  placenta  had  somewliat  constant  characters.  It  was  of  laiuv 
size,  and  of  great  weight  (3  lbs.  in  one  case,  3i  ll.is.  in  anotlier,  and  as 
much  as  6  lbs.  in  a  third);  and  it  was  nearly  always  soft  in  con- 
sistence, markedly  oedematous,  and  easily  torn.  It  was  also  coumionly 
anwmic  and  pale,  almost  Heecy  white  in  colour.  W.  Jakesch  {L'l  n- 
tralhl.f.  Gyniik.,  ii.  019,  1878),  witli  what  he  admitted  to  be  a  souk- 
what  daring  freedom  of  imagination,  compared  the  birth  of  the 
placenta  to  the  slow  rolling  forth  of  wool  from  an  overfilled  torn 
woolsack  ("  dem  langsameu  Hervorwiilzen  von  Wolle  aus  einem 
uberfiillten  angerissenen  Wollsacke").  The  umbilical  cord  was 
commonly  thick  and  oedematous,  often  friable,  and  sometimes  irre- 
gularly inserted  into  the  placenta.  In  one  case,  the  chorion  and 
amnion  were  thickened;  but  it  was  seldom  that  any  allusion  to 
their  characters  was  made.  Hydramnios  was  a  common  but  not  a 
constant  concomitant  condition.  In  a  few  cases  the  microscopic 
appearances  of  the  placenta  were  mentioned.  In  one  of  my  cases  the 
villi  of  the  chorion  were  swollen,  showed  a  slight  increase  in  the 
amount  of  stroma,  and  had  some  degree  of  oedema  in  their  epithelial 
covering.  In  Siefart's  case  (Monatschr.  f.  Gchurtsh.  u.  Gynuck.,  \m. 
215,  1898)  the  villi  were  very  large,  the  inter\'illous  spaces  were 
small  and  contained  little  blood,  the  stroma  of  the  villi  was  oedematous, 
and  the  walls  of  the  capillaries  were  thickened. 

With  general  fcetal  dropsy,  as  with  all  tlic  so-called  idiopathic 
foetal  diseases,  the  ^)a</(o,'/f?w'.sw  is  very  obscure,  and  even  tlie  etiology 
is  imperfectly  known.  Doulitless,  if  the  obscurity  were  less  marked,  , 
the  disease  would  be  found  to  have  passed  out  of  the  group  of  the 
idiopathic  di.seases  into  that  of  the  transmitted  morbid  states.  At 
the  same  time,  it  must  be  borne  m  mind  that  investigators  have  some- 
times made  these  questions  more  difficult  than  need  be.  For  instance, 
it  has  seldom  fallen  to  the  lot  of  one  observer  to  examine  more  than 
one  or  two  cases  of  the  disease,  and  it  lias  followed,  naturally  enough, 
that  he  has  considered  these  cases  as  typical  ones.  Now,  if  a  jihysician's 
knowledge  of  dropsy  in  the  adult  were  limited  to  two  or  three  cases,  , 
it  is  not  likely  that  it  would  be  at  all  sufficient.  Further,  there  is  no 
reason  to  expect  tliat  all  cases  of   fcptal  dro]isy  sliall  be  due  to  one 


GENERAL   F(KTAL    UHOl'.SV  295 

ami  the  same  cause  or  shall  present  identical  characters ;  in  the  adult, 
dropsy  is  a  sign  of  various  att'ections  residing  in  various  organs ;  the 
same  state  of  things  may  hold  regarding  foetal  dropsy.  Unfor- 
tunately these  almost  self-evident  facts  have  not  always  been  kept 
in  mind. 

According  to  some  writers,  the  cause  of  fcetal  dropsy  is  to  be 
sought  for  in  purely  maternal  states.  ]\Iaternal  alcoholism,  maternal 
hydra'Uiia,  and  maternal  nephritis  have  all  been  adduced  as  possible 
factors.  H.  Strauch  {Dissert.,  Berlin,  1880)  strongly  advocated  the 
theory  ,of  maternal  nephritis :  the  mother  had  a  contracted  kidney, 
producing  increased  arterial  tension  and  venous  stasis ;  there  was, 
therefore,  increased  pressure  in  the  maternal  portion  of  the  placenta 
and  an  exudation  of  serum  into  the  inter\"illous  spaces,  an  occurrence 
further  predisposed  to  by  the  hydremic  state  of  the  maternal  blood  ; 
the  placenta  being  the  place  of  least  resistance,  cedema  occurred  there 
even  if  not  in  the  other  maternal  organs ;  and  the  blood  coming  from 
the  fretus  in  the  umbilical  aiteries  met  with  resistance  in  the 
placenta,  which  caused  increased  venous  pressure  and  oedema  in  the 
foetus.  A  purely  paternal  cause  has  been  referred  to  tentatively  by 
some  writers,  and  it  is  a  suggestive  fact  that  the  first  four  cases  of 
the  disease  whicli  I  met  with  were  the  offspring  of  a  woman  and  her 
sister-in-law,  and  both  the  woman  and  her  brother  showecl  the  same 
gravely  amiemic  state. 

According  to  other  writers,  the  cause  of  foetal  dropsy  resides  in  the 
foetus  itself,  and  the  disease  is  truly  idiopathic.  Thus  Lawson  Tait 
{loc.  cit.)  thought  that  he  had  found  the  fons  et  origo  morhi  in 
premature  closure  of  the  foramen  ovale ;  the  closure  was  not  complete, 
a  crescentic  valvular  opening  yV-inch  in  size  forming  the  communica- 
tion between  the  two  auricles.  W.  Osier  {Keating's  Cyclop.  Dis. 
Children,  ii.  752,  1889)  found  a  very  similar  cardiac  anomaly,  but  he 
could  not  recognise  a  very  clear  connection  between  the  state  of  the 
heart  and  the  fcetal  disease.  Other  writers  looked  to  the  cystic  state 
of  the  kidneys  as  the  cause,  obviously  a  very  inadecpiate  theory. 
G.  Eaineri  (Gaz.  vied,  di  Torino,  xliii.  21,  1892)  considered  that  the 
oedema  of  the  foetus  and  placenta  might  be  ascribed  to  the  hindrance 
of  the  hepatic  circidation  and  the  obstruction  of  the  renal  secretion, 
due  to  the  infiltration  of  these  organs  with  leucocj'tes,  for  he  regarded 
the  state  of  the  liver  as  similar  to  the  interstitial  hepatitis  of  the 
syphditic  foetus.  Abnormal  states  of  the  foetal  blood  have  been 
regarded  by  some  as  the  causes  of  the  dropsy,  and  perhaps  the  most 
popular  of  recent  theories  has  been  that  of  a  "  leukiemoid  if  not 
perfectly  leuka-mic  "  condition. 

Finally,  many  writers,  recognising  the  inadequateuess  of  either  the 
maternal  or  the  fcetal  causes,  have  sought  for  coexisting  causal  condi- 
tions in  both  mother  and  foetus.  Virchow  {loc.  cit.),  for  instance,  found 
the  immediate  causes  of  the  dropsy  in  narrowing  of  the  pulmonary 
ostium  of  the  heart,  accompanied  bj'  cirrliosis  of  the  liver  and  incipi- 
ent granular  degeneration  of  the  kidneys.  The  state  of  the  heart  he 
ascribed  to  foetal  endocarditis,  and  this  in  its  turn  he  sought  to  trace 
to  syphilis  or  rheumatism  in  the  mother,  but  could  get  no  information 


296  ANTl'.NATAI.    I'A  11  l()I.()(iV    AM)    mXUKNE 

oil  the  innul.  The  thninilioses  in  the  iiiateiiial  placental  sinuses  he 
regarded  as  a  third  series  nf  disturbances,  wliich  by  liindeiing  the 
circulation  in  the  ftptus  tended  still  further  to  iironiotc  the  general 
dropsy.  Siinger  (loc.  cit.)  regarded  maternal  nephritis  as  the  primary 
cause:  this  set  up  leukiemia  in  the  fu'tus,  not  in  a  mechanical  way. 
but  because  the  hydnemic  state  of  the  mother's  blood  interfered  with 
the  normal  formation  of  the  foetal.  The  leuka'iuia  thus  produced  wa> 
the  immediate  cause  of  the  dropsy,  for  the  conversion  of  leucocytes 
into  erythrocytes  being  interfered  with,  the  f( inner  accumulated  in  the 
fo'tal  blood,  escaped  through  the  thin  vessel  walls,  and  formed  lymjih- 
oid  infarcts  hi  the  skin  and  glandular  and  other  organs,  and  serum, 
escaping  along  with  the  leucocytes,  caused  oedema  of  these  structures. 
Sanger  considered  that  a  similar  transudation  of  serum  took  place  in 
the  foetal  part  of  the  placenta,  and  that  Huid  passed  from  the  vessels 
of  the  villi  into  the  stroma.  Fuhr  (c^j.  cif.),  also,  looked  for  a  complex 
causation.  He  summarised  the  pathogenetic  stages  thus : — (1)  Chronic 
maternal  endometritis,  intensihed  by  nephritis;  (2)  hyperplasia  of 
the  chorionic  villi  due  to  decidual  increase  following  u])on  the  endo- 
metritis ;  (3)  excessive  ab-sorjition  of  Huid  blood  into  the  fcetal 
circulation  (partly  from  maternal  hydramia),  over-filling  of  the 
circulation  in  the  foetus,  with  resulting  obstruction  and  oedema;  (4) 
hydramnios,  due  to  increased  secretion  from  the  fwtal  kidneys,  an 
increase,  not,  however,  sufhcient  to  overcome  the  obstruction ;  and 
(5)  oedema  of  the  placenta  due  to  secondary  obstruction  in  that 
organ. 

It  is  of  course  quite  clear  from  all  that  has  been  stated,  that  the 
pathogenesis  of  foetal  dropsy  is  obscure ;  it  is  probable  also  that  its 
obscurity  has  been  increased  by  neglect  of  a  proper  comi^rehension  of 
the  peculiarities  of  foetal  physiology.  It  would  seem  that  it  must,  in 
the  first  place,  be  admitted  that  its  causes  are  not  always  the  same: 
as  in  postnatal  so  in  antenatal  life  dropsy  is  a  sign  of  ^•arious  morbid 
states.  Provisionally  it  may  be  supposed  that  general  o-dema  of  the 
faHus  may  arise  in  the  later  months  of  fcetal  life  from  maternal  causes ; 
possibly,  conditions  which  increase  the  blood  pressure  in  the  placenta, 
by  causing  structural  changes  in  its  maternal  and  (secondarily)  in  its 
foetal  parts,  may  thus  lead  to  liackward  pressure  and  transudation  of 
serum  in  the  foetal  body.  Again,  it  may  be  supposed  that  in  the  early 
foetal  or  late  embryonic  period  structural  anomalies  may  arise  in  the 
foetus  (heart,  kidneys,  liver,  blood)  which  will  directly  produce  the 
dropsy  as  it  is  produced  in  the  adult,  although  with  slight  diherences 
and  exaggerations  on  account  of  the  peculiarities  of  the  intrauterine 
environment.  These  fa'tal  conditions,  it  may  yet  be  found  possible 
to  trace  liack  again  to  morljid  maternal  states  :  and  it  may  even 
be  that  maternal  or  paternal  conditions  existing  in  the  sexual 
cells  before  impregnation  may  be  potent  to  direct  the  life  of 
the  impregnated  ovum  into  abnormal  manifestations.  Let  us 
here  leave  this  subject :  it  is  clear  that  it  is  obscure ;  thi.s  alone  is 
clear. 

It  can  scarcely  he  hoped  that  much  success  will  attend  attempts 
at  antenatal  diagnosis  in  regard  to  general  foetal  dropsy.    The  presence 


CYSTIC   ELEPHANTIASIS  297 

of  the  maternal  morbid  states  (dropsy,  albuminuria,  heart  disease,  etc.) 
which  have  been  regarded  as  causal  may  arouse  suspicion,  and  the 
history  of  the  earlier  occurrence  of  a  dropsical  fcetus  in  the  same 
family  may  greatly  strengthen  the  suspicion  ;  the  diagnosis  of  hydram- 
nios  will  also  aid.  As  a  rule,  however,  the  foetal  disease  will  only  be 
detected  during  the  progress  of  labour,  and  the  sooner  it  is  then 
detected  the  better  will  it  be  for  the  patient  and  her  medical 
attendant. 

The  antenatal  treatment  will  consist  in  the  correction  of  maternal 
disorders  by  means  of  milk  diet,  iron,  chlorate  of  potash,  strychnine, 
etc.,  and  will  be  possible,  as  a  rule,  only  when  the  mother  has  already- 
given  birth  to  a  dropsical  infant  in  an  earlier  pregnancy.  The  intra- 
natal treatment  will  take  the  form  of  a  reduction  of  the  bulk  of  the 
foetus  by  the  aspiration  of  the  peritoneal  effusion ;  extractive  inter- 
ference (forceps,  hands)  may  be  needed  before  the  child  can  be  born. 
After  birth  the  aspiration  of  the  thoracic  cavity  might  be  practised  in 
the  hope  that  respiration  might  be  established,  and  that  the  dropsical 
conditions  would  gradually  disappear.  I  have  had  under  my  care  a 
case  of  A'ery  serious  neonatal  anasarca  which  ultimately  recovered,  and 
I  am  inclined  to  hope  for  a  similar  happy  result  in  some  cases  of 
antenatal  oedema.  In  some  instances,  at  any  rate,  the  examination 
of  the  tissues  and  organs  showed  no  lesions  sufficiently  grave  to 
exclude  all  hope  of  independent  postnatal  life,  if  once  the  pulmonary 
respiration  could  lie  fully  established.  *S)jcs  incerta,  perhaps ;  but  still 
a  flicker  of  hope. 

Congenital  Cystic  Elephantiasis. 

The  curious  deforming  malady  known  as  congenital  cystic  elephan- 
tiasis is  probably  nearly  related  to  general  foetal  dropsy.  It  is, 
however,  a  disease  which  affects  chiefly  the  subcutaneous  tissue,  leading 
to  an  increase  in  its  dimensions  and  the  formation  in  it  of  cysts  of 
various  sizes,  with  clear  serous  or  curd-like  contents.  It  may  impli- 
cate the  subcutaneous  tissue  all  over  the  body,  but  frequently  it  is 
very  pronounced  in  a  special  region,  e.g.  the  back  of  the  head  and 
neck.  Fluid  in  the  body  cavities  is  sometimes  but  not  always  met 
with,  and  in  this  character  the  disease  differs  from  general  foetal 
dropsy.  Cystic  elephantiasis  is  doubtless  related  also  to  the  local 
conditions  known  as  cystic  hygroma  of  the  neck,  fibroma  moUuscum, 
and  some  forms  of  congenital  sacral  tumour. 

There  are  not  many  cases  on  record  in  which  the  morbid  condition 
of  the  subcutaneous  tissue  was  the  sole  anomaly  from  which  the  foetus 
suffered ;  in  fact,  the  disease  is  very  rare  alone.  There  are,  however, 
not  a  few  cases  in  which  it  occurred  along  with  grave  malformations 
or  in  associatiim  with  other  foetal  diseases.  Thus,  there  are  instances 
in  which  it  was  met  with  in  the  grossly  malformed  twin  of  the  so- 
Ccxlled  parasitic  type,  as  in  the  specimen  described  by  me  in  1S92 
(Diseases  of  the  Fcdus,  i.  p.  18-1) ;  and  F.  Caruso  {Arch,  di  ostet.  c  ginec., 
vi.  193,  1899)  has  put  on  record  a  case  in  which  it  was  combined  with 
foetal  "  rickets."     If,  however,  we  confine  our  attention  to  the  cases  in 


208  ANTENATAL    I'ATllOl.OCiV    AND    H'lCaKNK 

whicli  llie  condition  of  tlie  subcutaneous  tissue  was  the  chief,  if  imi 
the  only  anomaly,  we  arrive  at  the  following  conclusions. 

The  mother  was  j^enerally  a  multipara,  and  had  enjoyed  fairly  good 
health  till  the  commencement  of  the  pregnancy  which  ended  in  the 
birth  (if  the  fo'tus  with  cystic  elephantiasis.  That  pregnancy  nearly 
always  ended  prematurely,  and  was  generally  associated  with  hydram- 
nios ;  and  during  its  course  the  mother  suffered  from  dropsy, 
albuminuria,  and  unusual  abdominal  distension,  with  the  symptomatic 
consequences  of  these  alterations.  The  infant  rarely  survived  birth, 
a  result  due  in  some  cases  as  much  to  the  prematurity  as  to  the  morbid 
changes. 

The  foetus  was  generally  larger  and  heavier  than  it  ought  to  have 
been.  Its  bizarre  appearance  was  due  not  so  much  to  the  general 
gelatinous  anasarca,  as  to  the  cystic  accumulations  in  the  subcutaneous 
tissue  of  special  areas.  A.  Meckel  (Arch.  f.  Anal.  u.  Fhi/sio/.,  y.  149, 
1828)  called  his  specimen  a  "  monstrose  Larve  eines  Fiitus  "  (monstrous 
mask  of  a  fcetus),  and  used  to  e.\hil)it  it  with  lions',  elephants',  and 
calves'  heads  as  an  example  of  what  the  older  writers  named  "  molae 
spuriiB  " ;  he  regarded  it  at  first  as  an  acephalus,  for  it  seemed  to 
consist  solely  of  a  trunk  with  limbs  bearing  a  fleshy,  spongy  mass 
instead  of  a  head  ;  but  when  he  came  to  make  a  section  through  the 
mass,  he  was  greatly  surpiised  to  find  underneath  a  well-formed  fictal 
face  (vide  Figs.  32,  33).  Meckel  said  he  felt  like  a  child  wdio  sees  a 
man,  masked  like  a  bear,  throw  away  the  mask  and  reveal  his  face. 
H.  Steinwirker's  specimen  (Dissert.,  Halle,  1872)  was  somewhat  similar 
in  appearance,  but  was  not  so  grossly  malformed ;  and  F.  Neelsen 
(Berl.  klin.  Wchnschr.,  xix.  36,  1882)  compared  his  case  of  cystic 
elephantiasis  to  the  plum  mannikins  of  tiie  Christmas  markets  in 
Germany. 

The  dissectional  appearances  varied  considerably.  In  C.  Everke's 
specimen  (Dissert.,  Marburg,  1883),  for  instance,  there  was  a  fibro- 
myxomatous  stratum,  6  mm.  in  thickness,  between  the  skin  and  the 
subjacent  muscles,  and  the  large  swelling  on  the  back  of  the  neck 
was  found  to  contain  six  smooth-walled  cysts  with  yellowisli  brown 
semi-Huid  contents ;  there  were  some  anomalies  of  the  abdominal 
viscera  (contracted  state  of  intestines,  enlarged  spleen,  etc.).  In 
A.  0.  Lindfors'  case  (Ztschr.  f.  Gehurtsh.  u.  Gyndk.,  xviii.  258,  1890) 
there  was  an  umbilical  hernia  and  an  amniotic  band  attached  to  the 
left  hand ;  there  was  a  large  occi]>ital  tumour  consisting  of  a  thin- 
walled  cyst  with  serous  contents ;  tlie  heart  showed  a  common  ventricle 
and  a  common  auriculo-ventricular  opening,  and  the  auricles  were  very 
incompletely  separated. 

Xeelsen  (lor.  rit.)  gave  details  regarding  the  mici-oscojiir  appearances 
of  his  sjiecimen.  The  skin  was  fairly  normal,  but  the  lymjihatics  of 
it  and  of  tiie  subcutaneous  and  intermuscular  structures  were  greatly 
dilated  and  tortuous,  and  here  and  there  formed  real  cystic  spaces ; 
possibly  the  large  cysts  marked  a  further  evolution  or  the  same 
changes.  In  one  or  two  cases  the  placenta  was  oedematous  and 
friable,  but  details  regarding  both  it  and  the  membranes  were  seldom 
forthcoming. 


CYSTIC   ELEPHANTIASIS 


299 


300  ANTKNATAl.    I'AlllOI.OCiV    AM)    HYCilKNl-. 

Tlie  utioUigy  was  most  oliscure  in  all  the  recordcMl  eases, — and 
there  seemed  to  l)e  nothing  to  suggest  a  maternal  cause.  The  nature 
of  the  morbid  process  was  a  condition  of  dilatation,  or  of  dilatation 
and  occlusion  of  lymphatic  spaces  and  vessels,  a  lymphangiectasis. 
Upon  this  point  most  of  the  observers  agreed ;  liut  whether  the 
distension  of  the  lymphatics  or  the  hyperplastic  changes  in  the 
subcutaneous  tissue  were  to  be  regarded  as  tlie  primary  phenomena 
there  was  very  considerable  difference  »{  (jpinion.  In  the  absence  of 
general  agreement  upon  these  questions,  it  is  needless  to  spend  time 
discussing  the  correctness  of  the  term  "  elephantiasis  "  as  applied  to 
the  disease.  In  all  probability  it  is  in  its  first  stages  oedematous 
in  its  nature  :  but  on  account  of  the  early  period  of  intrauterine  life  at 
which  it  commences  it  takes  on  changes  (due  to  the  embryonic  state 
of  the  tissues)  of  a  quite  peculiar  kind,  changes  which  are  not  easily 
reconciled  with  the  alterations  found  in  later  antenatal  life.  Of 
course  it  is  not  the  same  disease  as  elephantiasis  Arabum,  but  it  is 
related  to  the  malady  known  as  congenital  elephantiasis,  a  morbid 
state  which  must  now  engage  our  attention.  4 

Congenital   Elephantiasis. 

Congenital  clcphiintiasis  is  a  name  which  has  been  somewhat 
widely  and  loosely  applied  to  all  the  hypertrophic  or  hyperplastic 
states  of  the  subcutaneous  tissue  or  tissues  which  may  be  present  at 
birth.  It  has,  as  we  have  seen,  been  given  to  the  soft  cystic  variety 
of  this  disease ;  it  is  given  also  to  the  widely  distributed  as  well  as 
to  the  strictly  localised  hard  and  soft  varieties  {elephantiasis  congenita 
dura,  mollis),  and  by  a  forced  process  of  extension  to  such  morbid 
states  as  multiple  cutaneous  neuro-fibromata  and  filjroma  moUuscum. 
At  one  end  of  the  series  of  pathological  changes  it  passes  over  by 
gradations  into  general  fcctal  dropsy  of  the  gelatinous  type  (as  seen 
more  particularly  in  the  twin  fcrtus),  and  at  the  other  end  into  a 
confused  and  heterogeneous  group  of  neoplasms,  including  nerve 
nsevus  (so  called)  and  congenital  unilatei-al  hypertrophy  or  partial 
giant-growth.  An  eminently  good  and  complete  account  of  this 
difficult  chapter  in  fcetal  pathology  is  given  by  F.  Ksmarcli  and 
D.  Kuleukampff  in  their  monograph.  Die  ElejJiantiastischen  Formoi 
(Hamburg,  I880),  which  extends  to  nearly  300  pages,  and  which 
contains  all  that  pathologists  (and  more  particularly  (Serman  patho- 
logists) had  said  on  this  matter  prior  to  the  year  1885.  It  is  not 
ray  intention  here  to  describe  the  three  forms  named  Elephantiasis 
telangiectodes,  E.  fibromatosa,  and  E.  neuromatodes ;  these  closely 
approximate  in  their  characters  to  the  congenital  neoplasms ;  hut  I 
shall  confine  myself  to  the  cases  of  hypertro]ihif  thickening  of  the 
subcutaneous  tissue  of  one  or  several  limlis  or  parts  of  the  body  which 
are  found  at  birth,  and  which  are  more  nearly  related  to  the  instances 
of  cystic  elephantiasis  (already  referred  to).  It  is  true  that  in  them 
the  vessels  and  nerves  and  even  the  bones  and  muscles  and  fibrous 
tissue  in  the  neighl)ourhood  may  be  involved  in  the  hyperplastic 
processes,  and  thus  connecting  links  with  elephantiasis  telangiectodes, 


coxgp:xital  elephantiasis  30 1 

neuroniatodes,  fibioniatosa  may  be  ibinieil ;  but  the  outstanding 
character  is  hyperplasia  of  tlie  subcutaneous  tissue  with  special 
involvement  of  the  lymphatics.  In  this  restricted  sense  let  us  deal 
with  congenital  elephantiasis. 

The  clinical  history  of  cases  of  congenital  elephantiasis  is  chiefly 
remarkable  for  the  occasional  record  of  iamily  prevalence  and  of 
hereditary  transmission.  M.  Xonne  {Arch.  f.  path.  Anat.,  cxxv.  189, 
1891),  for  instance,  met  with  eight  instances  of  the  disease  in  fourteen 
individuals  in  the  same  family  in  three  generations.  There  was  the 
man  H.  H.,  whose  age  when  examined  by  Nonne  was  34  :  his  father  had 
been  healthy,  but  his  mother  had  suflered  from  a  congenital  enlargement 
of  the  lower  limbs.  H.  H.  was  born  normal,  but  almost  immediately 
afterwards  it  was  noticed  that  his  feet  and  legs  were  unusually  large, 
and  the  enlarged  extremities  grew  proportionately  with  the  rest  of 
the  body.  The  hypertrophy  was  chiefly  below  the  knee,  and  aflected 
very  markedly  the  dorsum  of  the  foot,  and  just  above  the  malleoli  were 
two  grooves  on  the  right  and  one  on  the  left  leg.  The  surface  of  the 
skin  had  a  normal  appearance  (elephantiasis  glabra),  but  there  were 
some  papillary  growths  attached  to  the  toes.  There  was  pitting  on 
firm  pressure,  and  the  pitting  remained  long.  H.  H.'s  sister,  H.  M.,  age 
30  years,  had  a  condition  very  similar  to  that  described  above  ;  but  in 
her  case  the  right  leg  and  foot  were  normal,  the  anomaly  being 
restricted  to  the  left  side ;  there  was  the  same  swelling  especially  of 
the  dorsimi  of  the  foot,  the  same  grooves,  and  the  same  papillary 
growths  attached  to  the  toes.  H.  M.  was  married  and  had  had  four 
pregnancies :  the  first  ended  in  the  birth  of  an  infant  with  enlarged 
lower  limljs,  who  died  in  infancy ;  the  second  was  an  acephalic 
(anencephalic  ?)  full-time  infant  with  similarly  affected  lower  ex- 
tremities ;  the  third  pregnancy  resulted  in  the  birth  of  a  female  child, 
still  alive  (age  6  j'ears),  with  elephautiasic  enlargement  of  the  right  leg 
and  foot ;  and  the  product  of  the  fourth  gestation  was  a  full-time 
male  infant,  showing  the  same  abnormality  in  both  lower  limbs  liut  in 
a  less  degree.  As  has  been  already  stated,  the  mother  of  H.  H.  and 
H.  M.  had  also  suffered  from  congenital  elephantiasis  of  the  legs,  and 
one  of  her  sisters  had  the  same  condition  in  a  more  aggravated  form. 
When  the  family  history  was  traced  further  back,  the  inevitable 
maternal  impression  appeared,  for  the  grandmother  of  H.  H.  and 
H.  M.  had  been  frightened  during  pregnancy  by  a  woman  with 
dropsical  legs.  J.  H.  Jopson's  two  cases  {Arch.  Fccliat.,  xv.  173, 
1898)  were  brothers,  and  their  father  had  suflered  like  them  from 
congenital  enlargement  of  both  lower  limbs  below  the  knees;  and 
Milroy  {Proc.  Nebraska  Med.  Soc,  p.  27,  1892)  recorded  twenty-two 
cases  of  hereditary  oedema  of  the  lower  limbs  in  ninety-seven 
individuals  in  six  generations,  and  in  all  but  two  the  oedema  was 
congenital. 

There  is,  as  a  rule,  little  information  to  be  obtained  regarding  the 
character  of  the  pregnancy  which  ends  in  the  birth  of  an  infant  with 
elephantiasis ;  but  one  of  iloncorvo's  cases  formed  an  important 
exception.  In  1895,  Dr.  Jloncorvo  (Eio  de  Janeiro)  kindly  sent  me 
a  photograph  of  a  little  patient  suffering  from  congenital  elephanti- 


.302 


ANTKNATAI.    I'A'I'IIOI.Od^"    AM)    IIVCilKNK 


asis,  which  is  repMiducL'd  liere  (vide  Fig.  ?A);  aiul  I  coimuuiiicated 
the  details  of  the  case  to  the  Ediiiburgh  Obstetrical  Society  at  its 
December  meeting  {Trans.  Edinh.  Ohst.  Soc,  xxi.  25,  liSOG).  The 
infant  was  a  male,  of  mixed  race,  five  months  old.  The  father  had 
suliercd  from  acquired  syphilis,  and  on  several  occasions  had  liad 
lynipliangitic  attacks  affecting  the  limbs,  and  principally  the  arms. 
The  mother,  a  half-breed  like  her  husband,  had  had  seven  childrin. 
of  whom  four  (the  first,  second,  fourth,  and  fifth)  were  already  dcml. 
While  nursing  her  second  last  infant  she  had  been  attacked  li\- 
lymphangitis  in  the  left  breast,  going  on  to  suppuration. 


FlK.  34.— Congenital  EIpiilianti.i.sis. 

During  the  last  pregnancy  she  had  had  several  falls,  followed  by  i 
more  or  less  troublesome  results.     The  fii'st,  a  fall  in  the  street,  with 
bruising  of  the  abdomen,  at  the  fourth  month,  had  been  followed  ' 
for  eight  days  by  abdominal  pains;  two  months  later,  the  abdomen  I 
was  bruised  again  by  a  second  traumatism  ;  this  was  succeeded  by  ■ 
abdominal  pain,  a  rigor,  and  rise  in  temjierature  ;   at    the    seventh  ' 
month  she  fell  across  the  tramway  rails  in  the  street,  agaiii  bruising 
the  hypogastrium,  which  became  the  seat  of  a  lymphangitic  attack, : 
going  on  to  suppuration  and  fever  of  a  remittent  type,  and  lasting 
about  a  week;  again,  at  the  eighth  month,  she  received  a  I)low  on 
the  al)domen.     Labour  took  i)lace  at  the  full  term,  and  it  was  at  once 
noticed  that  although  the  infant  was  alive  and  active,  he  had  an  ab- 


CONGENITAL   ELEPHANTIASIS  :',0:5 

normally  large  right  lower  limb.  He  showed,  also,  signs  of  hereditary 
syphilis.  There  was  marked  hypertrophy  of  the  right  lower  limb 
from  groin  to  foot,  which  was  most  evident  in  the  foot  and  lower 
two-thirds  of  the  leg,  and  there  were  deep  grooves  to  be  recognised 
(Fig.  34).  The  skin  was  smooth  and  of  normal  colour  and  tempera- 
ture, but  drier  than  in  other  regions,  and  firmly  adherent  to  the 
subcutaneous  tissue.  Palpation  revealed  a  feeling  of  elastic  hard- 
ness of  the  tissues,  more  marked  on  the  dorsum  of  the  foot,  less  so  on 
the  thigh.  The  circumferential  measurements  of  the  right  thigh 
were  about  2  cms.  greater  than  those  of  the  left,  while  those  of  the 
leg  and  foot  were  from  4  cms.  to  6  cms.  greater  in  the  right  than  in 
the  left  limb.  Sensibility  to  touch  and  the  reaction  to  electricity 
were  less  marked  in  the  right  than  in  the  left  leg.  The  micro- 
scopic examination  of  the  mother's  blood  showed  only  a  slight 
exaggeration  of  the  number  of  leucocytes,  whilst  blood  serum 
taken  from  the  lower  third  of  the  right  leg  of  the  infant 
revealed  the  presence  of  a  certain  number  of  tlie  streptococci  of 
Fehleisen,  either  single  or  grouped,  as  diplococci  or  in  chains.  The 
infant  was  put  on  a  course  of  iodide  of  potassium,  and  the  limb  was 
subjected  to  elastic  compression,  with  the  result  that  the  dimensions 
of  the  hypertrophied  extremity  were  considerably  reduced.  This  was 
the  tenth  case  which  Dr.  Moncorvo  had  seen  {Satellite,  vi.  35,  1892  ; 
Ann.  dc  derviat.  et  syph.,  3  s.,  iv.  233,  1893 ;  ibid.,  v.  186,  1894 ; 
Journ.  de  elin.  et  de  therap.  inf.,  iii.  663,  1895),  and  in  one  or  two  of 
them  there  was  a  family  history  of  proclivity  to  lymphangitic  attacks. 
Further,  in  one  of  the  three  new  cases  which  he  contributed  to  my 
journal  {Teratologia,  ii.  79, 1895)  in  1895,  there  was  a  doubtful  history 
of  abdominal  traumatism  and  lymphangitis  in  the  mother  at  the 
eiglith  month  of  pregnancy.  I  have  given  full  details  of  Moncorvo 's 
cases,  for  they  have  an  important  bearing  upon  the  question  of 
pathogenesis,  to  which  reference  will  immediately  be  made. 

Some  idea  of  the  si/mptomatology  and  physical  signs  of  foetal 
elephantiasis  will  have  been  gained  from  what  has  lieen  recorded 
above ;  but  certain  facts  may  be  added.  Although  the  lower  limbs 
are  frequently  the  seat  of  the  disease,  they  are  not  constantly  so ; 
for,  while  they  were  afi'ected  in  the  cases  already  mentioned  and  in 
those  described  by  Otto  Schloss  (Dissert,  Bonn,  1890),  P.  Archambault 
{Ann.  de  dcrmat.  et  syph.,  3  s.,  iv.  448,  1893),  Waitz  {Arch.  /.  klin. 
Chir.,  xxxix.  229,  1889),  and  Steinthal  {Med.  Cor.-Bl.  d.  ^viirttcmh. 
arztl.  Ver.,  Ixvi.  33,  1896),  yet  in  that  reported  by  Osier  {Journ. 
Anat.  and.  Physiol.,  xiv.  10,  1879)  it  was  the  right  upper  limb,  in 
W.  B.  Coley's  {New  York  Med.  Journ.,  liii.  706,  1891)  it  was  the  face 
and  scalp,  in  T.  Spietschka's  {Arch.  f.  Dermat.  u.  Syph.,  xxiii.  745, 
1891)  it  was  the  whole  body  except  the  right  upjjer  limb  and  the 
genitals,  and  in  M.  Mainzer's  {Deutsche  med.  Wchnschr.,  xxv.  436, 
1899)  it  was  the  left  upper  limb  and  the  external  genitals  as  well  as 
the  lower  extremities.  In  most  of  the  cases  the  condition  did  not 
interfere  with  the  postnatal  life  of  the  child,  and  in  some  there  was 
a  distinct  tendency  to  diminution  in  the  amount  of  the  subcutaneous 
hypertrophy.     There  was  some  difficulty  in  progression  when  the 


J04 


ANTKNATAI,    I'A  11  lOI.OCiV    AM)    H^(;ll■.M■. 


lower  limbs  were  affected  ;  there  was  always  the  deformity ;  and  in  n 
few  Cfises  the  usefulness  of  the  liniljs  was  seriously  interfered  with. 
The  skin  covering  the  diseased  part  was  generally  normal  in  appear- 
ance, but  in  a  few  cases  there  was  an  excessive  vascular  development, 
and  in  one  of  Rose's  cases  ( .Vonatsschr.  f.  Gehurtslc,  xxx.  339,  1867) 
the  enlargement  was  almost  entirely  due  to  fat.  Now  and  again 
grooves  wei'e  described  on  the  allected  limbs,  and  in  G.  Iteinbacli's 
case  {Beitr.  z.  Jdin.  Chir.,  xx.  G45,  1898)  the  grooves  seem  lo  have 
been  due  to  amniotic  bands  encircling  the  part.  Although  in  most  of 
the  cases  the  ajjpearances  did  not  closely  resemble  elephantiasis 
Arabum  as  met  with  in  the  adult,  they  did  so  in  a  very  striking  way 
in  the  patients  seen  liy  Mainzer  {loc.  cit.)  and  Eeinbach  {loc.  cii.).  In 
the  former  the  external  genitals  were  affected  :  the  labia  majora,  the 
nymphw,  and  the  clitoris  all  showed  the  elephantiasic  thickening, 
and  between  the  posterior  commissure  and  the  anus  was  a  reduplica- 
tion of  loose  skin.  Both  legs  and  the  right  foot  exhibited  the  same 
enlargement,  which  by  the  help  of  the  Kiintgen  rays  was  seen  to 
have  left  the  bones  untouched.  The  left  upper  limb  was  enormously 
enlarged,  and  the  thickening  was  especialh'  marked  in  the  forearm 
aud  hand.  On  the  toes  of  the  right  foot  were  some  grooves  suggest- 
ing amniotic  bands.  The  skin  everywhere  retained  its  normal  colour, 
and  there  were  no  traces  of  angiomata  or  fibromata ;  but  in  the  areas 
of  thickening  there  was  some  cutaneous  dryness  and  roughness.  The 
child  had  neither  heart  disease  nor  nephritis,  and  the  thyroid  felt 
normal ;  there  was  no  syphilis. 

It  is  a  curious  speculation  to  inquire  whether  the  fabulous  people, 
the  Sciapodi,  described  by  Ctesias,  had  perchance  their  origin  in  the 
birth  of  an  infant  with  congenital  elephantiasis  of  one  foot.  They 
are  represented  as  possessing  a  single  foot  which  was  so  large  as  to 
be  used  as  a  sunshade,  aud  pictures  of  them  are  to  be  found  in  the 
older  works  on  Jlonstrosities. 

The  jxithogenesis  of  congenital  elephantiasis  has  that  common 
character  of  antenatal  morbid  states — obscurity.  It  has  lieen  sug- 
gested that  the  hypertrophy  may  be  due  to  an  amniotic  liand  encircling 
the  limb ;  aud  in  a  case  of  multiple  nialformatious  in  a  fcetus  which 
I  examined  some  years  ago,  there  were  indications  that  this  view 
might  occasionally  be  correct.  In  J.  Schnitzler's  case  (  Wiener  klin. 
Rundschau,  ix.  165,  1895),  also,  there  was  confirmatory  evidence. 
But  obviously  it  cannot  account  for  all  the  cases.  Some  have  seen 
in  the  disease  a  true  elephantiasis  Arabum  of  intrauterine  origin; 
but  there  is  next  to  no  evidence  of  the  transplacental  transmission 
of  this  disease  (vide  Prince  A.  Slorrow,  in  Twentieth  Century  Praeticc, 
xviii.  424,  1899),  and  E.  Sarra  (Pediatria,  iii.  155,  1895)  found  no 
traces  of  filarire  in  a  case  of  fretal  elephantiasis  examined  by  him. 
Its  origin  in  the  passage  of  streptococci  from  mother  to  infant,  which 
was  supported  by  Moncorvo,  cannot  be  accepted  as  frequently  correct, 
for  it  is  rare  to  find  any  liislory  of  maternal  lymphangitis  or  erysipelas 
in  pregnancy.  A  family  predisposition  to  neoplastic  changes  in  the 
connective  tissues,  as  imagined  by  Spietschka,  cannot  be  accepted 
as  a  satisfactory  explanation,  for   family  prevalence  and   heredity, 


CONGENITAL   ELEPHANTIASIS  305 

although  met  with,  are  not  at  all  frequent.  It  may  possibly  be  due 
to  long-continued  irritation  of  the  subcutaneous  tissues  by  some 
toxin  circulating  in  the  blood;  but  this  supposition  does  not  of 
course  satisfy  the  requirements  of  an  adequate  theory  of  patho- 
genesis. 

It  is  cheering  to  be  able  to  chronicle  improvement  and  even 
recovery  under  ti-eatment  with  iodide  of  potassium,  electricity,  and 
elastic  compression.  There  is  sometimes  a  natural  tendency  towards 
cure,  and  possibly  to  this,  as  much  as  to  the  treatment,  the  improve- 
ment may  be  due.  So  that,  after  all,  the  cheerfulness  of  the  believer 
in  therapeutic  successes  in  antenatal  maladies  may  be  premature. 

The  above  maladies  (general  foetal  dropsy,  general  cystic  elephan- 
tiasis, and  congenital  elephantiasis)  I  have  selected  as  types  of 
idiopathic  diseases  affecting  chiefly  the  subcutaneous  tissue ;  but  it 
will  be  evident  to  the  reader  that  indications  are  not  wanting  of 
their  possible  transmitted  character.  In  some  instances,  at  least, 
there  is  ground  for  believing  that  the  maternal  (or  paternal)  health 
had  a  determining  influence  upon  the  evolution  of  the  fcetal  malady. 
The  diseases  are  retained  in  the  idiopathic  group,  but  there  is  reason 
to  expect  that  ere  long  they  will  have  to  be  transferred  to  the 
transmitted. 

There  are  also  certam  morbid  states  of  the  subcutaneous  tissue 
which  have  not  yet  been  established  as  truly  present  at  birth ;  among 
these  is  myxoedema,  due  to  the  absence  of  the  thyroid  gland.  Bourne- 
ville  {Progres  vied.,  3  s.,  ii.  33,  49,  1895)  explains  the  absence  of  the 
symptoms  of  myxoedema  in  the  early  months  of  life  as  due  to  the 
influence  of  the  mother's  milk ;  after  weaning,  the  defective  state  of 
the  thyroid  makes  itself  felt,  and  the  pachydermatic  cachexia  be- 
comes evident.  It  seems  more  probable,  however,  that  the  thyroid 
in  the  foetus  and  at  birth  does  not  possess  the  same  regulating 
influence  over  body  metabolism  (including  of  coui'se  that  of  the  sub- 
cutaneous tissue)  as  it  does  later ;  possibly,  therefore,  its  defective 
action  will  not  reveal  itself  by  the  same  alterations  in  the  subcut- 
aneous and  other  tissues  at  birth  as  it  does  later  (vide  p.  166). 

Atrophic  as  well  as  hypertrophic  states  of  the  subcutaneous  tissue 
have  been  met  with  in  the  foetus.  F.  Ahlfeld  (Berl.  Jdin.  Wchnschr., 
xxxi.  812,  1894),  for  instance,  has  described  a  foetus  with  atrophy  of 
the  subcutaneous  adipose  tissue  in  a  case  of  defect  of  the  liquor  amnii 
(ohgohydramnion) ;  the  mother  was  a  deaf-mute,  and  so  perhaps  was 
the  father.  Possibly  the  "  living  skeletons  "  who  are  exhibited  at 
shows  and  fairs  and  Christmas  carnivals  are  in  some  cases  examples 
of  this  congenital  atrophic  state  of  the  subcutaneous  tissues.  The 
so-called  "  elastic  skinned  men,"  also,  show  a  condition  which  is 
probably  due  to  congenital  defective  growth  of  the  subdermal  rather 
than  to  abnormal  elasticity  of  the  dermal  tissues. 


CHAPTER   XVI II 

Idiopatliic  Diseases  of  the  Fiutus  (cont.):  Types  of  Skin  Diseases:  Fdtal 
Ichtliyosis  (Grave  Form) — Definition,  Synonyms,  Clinical  History,  Sympto- 
matology, Ai)pearances  (Macroscopic  and  Microscopic)  ;  Fu'tal  Iclithyosis 
(Mild  Form)  ;  Tylosis  Palm;e  et  Planta; ;  Ffital  Keratolysis ;  Ilyper- 
trioliosis  congenita — Definition,  Synonyms,  Recorded  Cases,  Clinical  History, 
Pathogenesis  ;  Localised  Form  of  Hypertrichosis  ;  Congenital  Alopecia — 
Clinical  Characters,  Pathogenesis  ;  Antenatal  Pemphigus  or  Epidermolysis 
bullosa  hereditaria  ;  Congenital  Absence  of  Skin  ;  Acanthoma  or  Amnioma 
of  the  Skin. 

Id  this  chapter  I  propose  to  consider  some  types  of  fcetal  disease  of 
the   skiu.     Some  difficulty  has   arisen   in  selecting  these  types,  for 
there  is  a  large  number  to  choose  from,  as  may  he  seen  liy  a  reference 
to  my  scheme  of  classification  of  foetal  skin  affections  {Diseases  of  the 
Faitus,  ii.  p.  227,  1895).     Some  of  the  maladies  therein  enumerated 
{e.g.,  those  connected  with  the  transmitted  morbid  states,  the  fevers, 
syphilis,  purpura)  have,  it  is  true,  been  already  considered ;  but  tliere 
still  remains  a  large  number  of  others.     From  these  I  select  fcetal 
ichthyosis  (one  of  the  epidermidoses),  tylosis  paluue  et  plauta'  (one 
of   the   acanthoses),  hypertrichosis  and   hypotrichosis   (two   of  the 
trichoses),  pemphigus  (one  of   the  angiotic  acantholyses),  and   con- 
genital absence  of  the  skin  (an  atrophic  dermatosis).     The  various 
forms  of  uffivus  I  do  not  specially  deal  with,  as  every  text-book  on 
Dermatology    and    Surgery    devotes    consideralile    space   to    them. 
The  same  general  principles  of  Antenatal  Pathology  {vide  Chapter 
XI.)  must  be  applied  to  the  study  of  the  skin  diseases  as  have  been 
applied  to  the   other   maladies  with  which  the  preceding  chapters 
have   been   occupied.     Incidentally  it   may  lie   remarked   that   the 
congenital  skin  diseases  have  come  prominently  before  tlie  notice  of 
the  pulilic  as  well  as  the  profession ;  for  the  sull'erers  from  thom  bulk    '■ 
largely  in  shows  at   fairs,  in    "  dime    museums,"   and   at   Christmas    ,■ 
carnivals.     The  curiositj'  of   the   public  with   regard   to   "alligator   /» 
boys,"    "  hairy  men,"  "  spotted  girls,"  and  "  freaks "  of  that  kind  is    ,j 
great,  and  while  it  may  be  far  from  commendable,  it,  at  any  rate,  pro-   ,( 
vides  funds  for  the  support  of  these  victims  of  antenatal  pathology.       ' 

Fcetal   Ichthyosis   (Grave  Form). 

This  malady  may  be  provisionally  defined  as  a  skin  disease  of 
the  faHus,  developed  probalily  about  the  fourth  mouth  of  intrauterine 
life,  characterised  by  the  existence  over  the  whole  surface  of  the  body 
of  horny  epidermic  plates,  separated  from  each  other  by  fissures  and 


Fa-:TAL   ICHTHYOSIS  oOT 

furrows,  associated  with  certain  deformities  of  the  moutli,  nose,  eyes, 
ears,  and  extremities,  and  leading  to  the  death  of  the  infant  very 
soon  after  birth. 

It  has  gone  under  various  names.  It  was  first  described  about 
the  end  of  the  eighteentli  century  (Eichter,  Disscrtatio  dc  IiifanticicUo, 
1792),  and  up  to  the  middle  of  the  nineteenth  century  it  was  called 
a  congenital  hypertrophy  of  the  epidermis  or  "  cutis  testacea " 
(Behrend,  Tlionogr.  Darstell.  der  niclit-syph.  Hautkr.,  p.  84,  Plate  xxix. 
1839).  A.  Keiller  {London  and  Edin.  Month.  Joiirn.  Med.  Sc,  iii.  694, 
1843)  simply  described  his  case  as  one  of  "  thickening  and  deep 
fissures  of  the  skin  in  an  infant  at  birth  " ;  but  J.  Y.  Simpson,  who 
communicated  Keiller's  case,  entitled  his  paper  "  Intrauterine 
Cutaneous  Disease,"  and  went  on  to  say  that  "  it  would  appear  to  he 
much  more  analogous  to  ichthyosis  than  to  any  other  skin  disease 
that  can  be  referred  to,  and  therefore,  suggested  for  it  the  name 
of  '  Ichthyosis  Intrauterina.' "  This  designation,  or  its  synonym 
"  Ichthyosis  congenita,"  has  been  widely  adopted  and  is  now  in 
general  use,  although  recently  there  has  been  a  tendency  to  prefer 
"  Hyperkeratosis  "  or  "  Keratoma."  The  peculiar  appearances  of  the 
infant  affected  with  this  disorder  have  led  to  the  occasional  employ- 
ment of  the  singularly  descriptive  name  of  "  Harlequin  Foetus " 
(Bland  Sutton,  Trans.  Med-Chir.  Soc.  Zand.,  2  s.,  li.  291,  1886). 

It  would  seem  that  the  disease  is  rare,  for  up  to  the  year  1895 
there  had  only  been  recorded  some  forty-two  cases ;  and,  taking  into 
account  the  very  striking  appearances  that  the  infants  present,  it  is 
unlikely  that  many  escape  recording. 

With  regard  to  clinical  history,  it  is  most  noteworthy  that  the 
parents  of  infants  suffering  from  ichthyosis  were  generally  themselves 
free  not  only  from  ichthyosis,  but  also  from  all  kinds  of  skin 
affections.  Anton  Wassmuth  (Beitr.  z.  path.  Anat.  n.  allg.  Path., 
xx\'i.  19,  1899),  however,  has  recorded  a  case  in  which  the  parents 
were  cretins.  The  obstetric  history  was  in  the  great  majority  of 
instances  good.  One  striking  fact,  however,  must  be  noted — the 
occm'rence  of  more  than  one  ichthyotic  infant  among  the  offspring  of 
the  same  parents,  or  family  prevalence.  Thus,  Okel's  two  specimens 
{Verm.  Abhandl.  v.  einer  Gesellsch.  pract.  Aerzte  zxi  St.  Petcrsb.,  viii. 
185,  1854)  were  borne  by  the  same  mother ;  so  were  Houel's  two 
eases  {Compt.  rend.  Soc.  de  hiol.,  iv.  177,  1853),  and  those  of  G.  A. 
Haus  {Norsk  Ma<j.f.  Laegevidensk.,  Ixii.  542,  1901) ;  and  the  mother  in 
Oestreicher's  record  {Arch.  f.  Dermat.  u.  Syph.,  xxiii.  837,  1891)  had 
three  normal  infants  by  her  husband,  and  after  his  death  three 
ichthyotic  foetuses  in  three  successive  years  illegitimately,  and 
presumably  by  the  same  man.  The  condition  of  the  foetal  skin 
seems  occasionally  to  have  retarded  the  progress  of  labour ;  but  a 
premature  ending  to  the  pregnancy  was  common.  Obscure  abnormal 
symptoms  have  been  described  by  the  mother  during  gestation ; 
hydramnios  has  been  met  with ;  and  there  has  been  the  usual  crop 
of  stories  of  maternal  impressions. 

The  infants  were  all  weakly  when  born,  and  died  within  a  few 
days  or  hours  thereafter ;  and  it  is  particularly  noteworthy  that  only 


308  ANIKNATAI.    I' ATI  lOI.OdV    AND    Il^dlKNE 

in  one  recorded  ease  (J.  F.  .lalin,  llhxcrt.,  I>eipzig,  18G'.))  was  tlie 
subjeel  dead-born,  so  that  it  may  he  conehuled  that  fu'tal  ielitliyosis  is 
not  fatal  to  intrauterine  althou<::h  it  is  most  uniformly  so  tn  post- 
natal existence.  Tliis  latter  result  is  in  large  measure  brought 
aljout  by  the  associated  deformities,  and  especially  by  the  state  of  the 
mouth,  whicii  practically  prevents  sucking.  The  child  usually  cried 
loudly  and  continuously  during  its  short  tenure  of  life ;  but  in  some 
cases  the  cry  was  weak  and  buzzing  ((r.  Vrolik,  Tab.  ad  illustr. 
Emhryog.,  1*1.  xcii.,  1849).  Respiration  was  impeded,  but  urination 
and  defecation  usually  took  ])lace  naturally;  in  Souty's  case  {Bull, 
de  I'Acad.  roy.  de  mi'd.,  viii.  82,  1842-3),  however,  no  urine  was 
passed.  In  most  instances  the  infant  slept  little,  and  in  some  cases 
(Jahn,  op.  cit.)  special  reference  was  made  to  the  highly  offensive, 
cadaveric  smell  which  came  from  the  skin. 

Tlie  appearances  of  the  general  body  surface,  with  its  thick  horny 
yellowish  epidermic  plates  of  all  sizes  and  shapes,  with  intervening 
cracks  or  fissures  of  a  red  or  bluish  tint,  are  very  characteristic 
(Fig.  35).  Some  of  the  older  authors  described  the  eyeballs  as  absent 
and  their  place  taken  by  two  red  tieshy  masses :  but  it  is  now  known 
that  these  tieshy  tumours  are  really  the  greath'  swollen  and  congested 
conjunctival  surface  of  the  eyelids  everted  in  ectropion  (Fig.  36),  for 
on  separating  these  we  can  see  the  normal  eyeball. 

The  whole  body  presents  a  particularly  hideous  and  repulsive 
appearance,  and  we  can  scarcely  wonder  that  such  epithets  as 
"horrilile"  and  "terrible"  have  been  freely  used  by  writers  in 
describing  their  specimens.  The  thickened  jilates  with  intervening 
fissures  have  been  compared  to  a  coat  of  mail,  to  the  bark  of  some 
trees,  to  the  dermal  covering  of  the  armadillo,  the  coat  of  the  tortoise, 
and  (by  a  stretching  of  the  imagination)  to  the  dress  of  the  harlequin. 
The  epidermic  layer  is  much  harder  than  usual ;  it  is  variously 
described  as  "  leather  like,"  "  horny,"  and  "cartilaginous"  ;  it  is  cold 
to  the  touch.  The  plates  differ  greatly  in  size  and  shape,  and  the 
appearance  produced  l)y  them  has  been  compared  by  Eadcliffe  Crocker 
(Diseases  of  the  Skin,  2nd  Edit.,  343,  1893)  to  a  "loosely-built  stone 
wall,"  to  a  stone-dyke  as  we  call  it  in  Scotland.  The  thickest  plates 
are  on  the  back,  chest,  and  scalp;  the  thinnest  ai-e  on  the  hands  and 
feet  and  round  the  anus  ;  their  margins  are  usually  bevelled  off  and 
their  surface  is  commonly  smooth,  but  sometimes  shows  small  spines. 
The  deepest  cracks  or  fissures  are  generally  found  on  the  scalp  in  the 
neighbourhood  of  the  greatly  deformed  ears ;  some  of  them  are 
bridged  over  by  a  thin,  transjiarent  pellicle,  but  this  is  often  absent. 
The  hands  and  feet  are  greatly  thickened  and  malformed  ;  the  digits 
reseudjle  birds'  claws  (onychogryphosis),  are  sometimes  united  to 
each  other,  and  are  sometimes  absent.  The  dissectional  appearances 
of  the  internal  organs  would  appear  to  be  unimportant :  congestion 
seems  to  have  been  fairly  constant,  and  the  cause  of  death  was 
generally  found  in  a  In-oncho-pneumonia  or  pulmonary  oedema.  In 
1901,  Drs.  A.  S.  Daniel  and  L.  Cordes  kindly  sent  me  a  photograph 
of  a  very  ty])ical  case  reiHirtod  liy  them  {Jonrn.  Amcr.  Med.  Assoc., 
XXXV.  1081,  1900).     In  tiiis  case  the  kidneys  showed  the  lesion  of 


FCETAL   ICHTHYOSIS 


309 


Fig.  35.— Sti-aiibe's  Case  of  Fcctal  Ichthyosis, 


310 


ANTKNATAI,    I'ATIIOLOGY   AND    llYdlKNE 


acute  exudative  nephritis;  the  rliild  had  died  suddenly  twenty-seven 
hours  after  birth. 

The  microscopical  apjmiranccH  of  tlie  skin  (Fi<,'s.  37,  08)  have  been 


Fk:.  30.— Kyliei's  Case  of  Fiutal  klithyosis. 

well  described  by  E.  Kyber  {Medizin.  Jahrh.,  .-^QT,  ISSO)  and  T. 
Carbonc  {Arch,  per  le  Sc.  vud,  xv.  349,  1891).  The  most 
striking  feature  is  the  enormous  thickening  of  the  epidermic  layer, 


FCETAL   ICHTHYOSIS 


311 


Fig.  37.— Skin  of  Palm  of  Hand  in  Fojtal  Ichtliyosis  (Kyber). 
Stratum  corneum  with  sweat  canals  ;  6,  Stratum  Malpigliii ;  c,  Projection 
passing  down  between  the  papillte  ;  d,  Sweat  ducts  ;  e,  Sweat  glands. 


312 


ANIKN'A'IAI.    I'AlllOI.OflV    AND    HYC.IF.NF, 


■  '-.^ 

i 

j    '; 

d 

i 

<i  '" 

/' 
d    6   ^''^'^-   b    d        ^    , 

•■V.'                 '   !S^ .                 3 
■■■.;                  1^^' 

■  ■: ..         ?i 

■  ■  ■•;           Sii 

e        ■  ■  ■                '■'!.  ■ 

'•.'       "'ii'-- 

^  '4k 

^^' 

Pig.  38.— KvIiit's  .•<).. 


if  r.-Ml  1.1, til- 


Fig.  1. — Vertical  Section  of  tlie  Skin  of  the  Clicst  in  a  thirkuiieil  area,  a.  Stratum 
(■oineiim,  with  liair  canals  containing;  lanugo  liairs  ;  6,  Stiatuni  tlal]>igliii  ;  c,  Sweat 
gland.s ;  d,  Hair  sac  ;  c  and  /,  Sdiaccous  glands  fdlcd  w  itli  fat  cells  ;  ;/,  Lanugo 
hairs  ;  A,  Cerium. 

Fig.  2. — Vertical  Section  of  Hair  Sac  with  Sebaceous  Gland  from  Skin  of  Head  (Kyher). 


FCETAL    ICHTHYOSIS  313 

which  is  ahnost  entirely  situated  in  the  stratum  corneum,  the  rete 
Malpighii,  with  the  exception  of  the  interpapillary  prolongations, 
being  even  diminished  in  tliickness  in  some  instances.  It  is  xisually 
stated  that  there  is  no  stratum  granulosum  of  Langerhans,  and  no 
layer  of  flattened  cells  containing  kerato-hyaline ;  but  G.  A.  Haus 
(loc.  cit.)  found  both.  There  is  a  well-marked  stratum  lucidum,  and 
the  passage  from  it  into  the  horny  layer  is  not  sudden  and  sharp  as 
in  normal  fcetuses  but  more  gradual.  In  the  normal  infant,  also, 
osmic  acid  stains  deeply  the  deepest  and  the  most  superficial  layers 
of  the  stratum  corneum,  leaving  the  intermediate  layers  vmstained ; 
but  in  foetal  ichthyosis  there  is  no  such  colour  reaction,  or  only  the 
presence  of  some  fine  black  lines.  This  diflerence  has  been 
attributed  to  impeded  sebaceous  secretion.  It  is  doubtful  whether 
the  cells  of  the  rete  Malpighii  show  signs  of  great  activity  or  not. 
The  hair  follicles  are,  in  many  instances,  completely  plugged  by  the 
thickened  horny  substance,  and  the  external  root  sheath  of  the  hair 
is  also  thickened.  The  sebaceous  glands  are  atrophied  and  the 
hairs  themselves  are  thin.  The  sudoriparous  glands,  however,  are 
hypertrophied  (Kyber)  and  their  ducts  are  elongated ;  but  Carbone  (loc. 
cit.)  did  not  note  this  hypertrophy.  The  cutis  vera  is  fairly  normal ; 
certainly  the  papilLe  are  longer  than  usual,  but  they  are  also  thinner, 
and  probably  are  not  much  if  at  all  increased.  The  amount  of 
adipose  tissue  is  smaller  than  usual,  but  the  subcutaneous  tissue,  like 
the  true  skin,  shows  feebly  indicated  alterations  or  none  at  all.  In 
the  furrows  between  the  horny  plates  the  histological  appearances 
differ  from  those  above  described,  chiefly  in  the  absence  of  any 
marked  thickening  of  the  stratum  corneum ;  and  the  rete  Malpighii 
may  be  made  up  of  only  two  or  three  rows  of  flattened  cells.  In 
some  of  the  deep  cracks  the  fissure  extends  directly  down  to  the 
cutis  vera,  upon  which  lie  only  some  pus  cells  and  broken-down 
epithelial  cells.     Intermediate  types  are  also  met  with. 

To  summarise :  the  changes  in  the  skin  consist  in  hyperkeratosis, 
along  with  the  results  which  this  alteration  produces  upon  the  hairs 
and  sebaceous  and  sudoriparous  glands.  The  condition  of  the  rete 
Malpighii  is  puzzling;  but  possibly  at  one  stage  or  another  in  the 
evolution  of  the  disease  it  may  show  signs  of  proliferative  activity. 
If,  however,  the  disease  is  primarily  due  to  an  anomalous  growth  of 
the  epitrichium  of  early  foetal  life,  it  may  not  be  necessary  to  look 
for  changes  in  the  rete  Malpighii.  The  chemical  analysis  of  the 
epidermic  scales,  made  by  B.  Livingstone  {Amer.  Journ.  Ohst,  xv. 
988,  1882)  showed  fat,  cholesterine,  and  possibly  hippuric  acid ;  and 
the  burnt  residue  was  made  up  of  salts  of  lime,  magnesia,  and  iron. 
Very  little  information  was  forthcoming  regarding  the  placenta, 
membranes,  and  cord ;  but  the  ejiidermic  thickening  does  not  seem 
to  have  extended  to  the  sheath  of  the  cord, — a  striking  fact.  There 
was  hydramnios  in  Jahn's  case  (Dissert.,  Leipzig,  1869)  and  in  W.  E. 
Smith's  {Amer.  Journ.  Ohst.,  xiii.  458,  1880), — also  striking  facts,  but 
standing  almost  alone.  A  thorough  investigation  of  the  foetal 
annexa  in  these  cases  is  a  desideratum. 

Fig.  3. — A'ertical  Section  of  Skin  of  Palm  of  Hand  in  a  Normal  Infant  (Kyber).  a. 
Stratum  corneum  ;  b.  Stratum  Malpighii ;  c,  Interpapillary  projections  ;  d,  Corium  ; 
e,  Sudoriparous  glands  ;  /,  Adipose  tissue. 

Fig.  4. — Transverse  Section  of  Hair  Sac  containing  Hair  from  Skin  of  Head  (Kj'ber). 


314  ANTENATAL   I'ATHOI.OCJV    AM)    IlY(iIKNi: 

The  etiology  of  ftt'tal  iehtliyosis  is  unknown.  The  parents  were 
generally  quite  free  fnjui  skin  disease  of  all  kinds  and  from  syjdiilis. 
Sex  seems  to  liave  no  imjioitance.  Fauiily  jirevalence,  however,  was 
unusually  common  when  we  remember  how  rare  the  disease  is ;  and 
in  one  case  (Carbone's)  the  parents  were  nearly  related  (uncle  and 
niece).  The  pathogenesis,  likewise,  is  most  obscure.  "NMietlier  or  not 
the  disease  is  ichthyosis  modified  by  intrauterine  environmental 
conditions,  is  after  all  comparatively  unimportant.  The  real  dilHculty 
is  to  find  any  explanation  for  the  extraordinary  thickness  of  the 
stratum  corneum  of  the  eiiidermis.  H.  C.  L.  Barkow  (JJeitr.  z.  path. 
Enttviekclungsgeschichte,  iv.  52,  I'reslau,  1871)  thoui;]it  tliat  the  first 
stage  in  the  production  of  the  disease  was  i)enq)higus:  after  the 
blebs  had  formed  they  burst  and  the  tears  remained  as  the  fissures 
between  the  epidermic  plates ;  the  hypertrophy  constituted  the 
second  stage.  There  is  little  to  commend  this  view,  for  IJarkow's  case 
seems  to  have  been  the  only  one  in  which  there  w-as  any  sign  of 
pemphigus.  A  more  attractive  theory  is  that  w"hich  regards  the 
thickened  horny  layer  of  the  epidermis  as  the  direct  derivative  of 
the  epitrichium  {q.v.,  page  85).  This  theory  has  been  commended 
by  Ohmann-Dumesuil  {Tcratologia,  ii.  149,  1895),  who  thinks  that 
through  an  arrest  in  the  development  of  the  hair  and  sebaceous 
glands  the  epitrichium  remains  attached  to  the  underlying  stratum 
corneum  and  stimulates  it  to  excessive  growth.  I  suggest,  however, . 
that  absence  or  defective  development  of  tlie  epitrichium,  also,  may  | 
permit  a  more  luxuriant  growth  of  the  underlying  horny  layer. 
Why  in  certain  cases  this  anomaly  in  the  formation  of  the  ei)itrichial  I 
layer  should  exist  is,  of  course,  a  difficult  question.  It  may  be  noted 
that  J.  M.  Winfield  (Journ.  Cutan.  and  Gen.-Urin.  Dis.,  xv.  516, 
1897)  has  recorded  a  case  of  congenital  ichthyosis  with  absence  of] 
the  thyroid.  If  we  accept  the  view  that  fojtal  ichthyosis  is  due 
either  to  persistence  or  to  absence  of  the  epitrichium,  we  place  the ' 
condition  among  the  monstrosities  rather  than  the  diseases  of 
antenatal  life ;  but  this  is  no  great  objection  to  the  theory.  For  it 
has  been  pointed  out  that  during  the  ftrtal  period  some  embryogenesis 
is  still  going  on  {e.g.,  in  the  skin),  and  morbid  causes  acting  on  these 
parts  still  in  the  embryonic  stage  would  produce  teratological  results. 
There  is  nothing  inherently  improbable  in  the  view'  that  fojtal 
ichthyosis  is  a  monstrosity  rather  than  a  disease.  Truly,  the  appear- 
ances which  it  presents  are  monstrous  enough  ! 

The  prognosis  in  cases  of  foetal  ichthyosis  is  of  the  gravest. 
Although  not  fatal  to  the  beginning  of  postnatal  life,  it  is  absolutely  ] 
so  to  its  continuance,  and  death  has  invariably  followed  at  a  time 
varying  from  a  few  hours  to  nine  days.  The  infant  is  often 
premature,  is  sometimes  inherently  weak,  is  unable  to  suck,  and  the 
cracks  and  fissures  in  the  skin  soon  become  "the  haiuits  of  pyogenic  \ 
microbes."  He  is  called  the  "  harle<[uin  foetus";  but  truly  liis 
postnatal  life  is  a  lirief  and  a  sad  harlequinade  enough  1 

Foetal  ichthyosis  has  been  noted  in  the  lower  animals  {e.g.,  the 
calf),  and  F.  Ii.  Liebreich  (Dissert.,  Halle,  1853)  has  found  a  possible 
paternal  cause  in  some  of  these  cases. 


I 


FCETAL   ICHTHYOSIS  315 

Foetal  Ichthyosis   (Mild  Form). 

An  infant  suffering  from  the  mild  type  of  fcetal  ichthyosis  is 
born  with  a  continuous  layer  of  a  collodion-like  substance  over  the 
whole  body ;  after  birth  this  substance  desquamates  in  small  tissue- 
])aper  like  tlakes.  It  is  sometimes  but  not  often  accompanied  by 
an  ectropion  condition  of  the  mouth,  eyes,  and  anus.  This  is  the 
"  collodiou  ftPtus  "  then ;  it  is  the  attenuated  form  of  foetal  ichthyosis 
(Hallopeau  and  Watelet,  An7i.  dc  dermat.  ct  syph.,  .3  s.,  iii.  149, 
1891'). 

In  this  type,  as  in  the  grave  form,  the  parents  are  generally  free 
from  all  kinds  of  skin  disease ;  and,  as  in  the  grave  form,  family 
prevalence  has  several  times  been  noticed.  Some  curious  occurrences  ^  __.0 
have  been  recorded.  In  a  case  of  H.  Auspitz  {Arch.  f.  Dermat.  u. 
Si/ph.,  i.  253,  1869),  the  pregnancy  was  plural,  the  twins  were  of 
different  se.xes,  the  ichthyotic  one  was  a  male  and  the  normal  one  a  _^- 
female.  In  F.  Warner's  observation  (Med.  Times  and  Gaz.,  p.  144,  i. 
for  1882),  two  sisters  married  their  cousins  (two  brothers),  and  each 
woman  gave  birth  to  an  ichthyotic  foetus.  In  G.  T.  Elliot's  case 
{Joiirn.  Cutcui.  and  Gen.-Urin.  Dis.,  ix.  20,  1891),  a  man,  wdio  had 
been  twice  married,  had  by  his  first  wife  healthy  children,  and  one 
with  palmar  hyperkeratosis ;  by  his  second  wife  he  had  two  ichthyotic 
infants.  Family  prevalence  was  met  with  by  ilichelson  {Berl.  klin. 
Wchnschr.,  xxiii.  520,  1886),  by  A.  J.  Munnich  {Monatsh.  f.  prakt 
Dermat.,  v.  240,  1886),  and  by  others. 

In  no  case  was  the  infant  born  dead,  and  in  only  a  few  instances 
did  it  succumb  soon  after  birth ;  so  the  mild  form  of  foetal  ichthyosis 
cannot  be  regarded  as  fatal  to  either  intrauterine  or  postnatal  life, 
although  it  is  exceedingly  difficult  to  cure  completely.  In  one  or 
two  instances  there  was  recovery,  in  others  there  was  a  localised 
involution  of  the  malady  with  a  tendency  to  revert ;  but  in  most  of 
the  cases  the  lesion  either  remained  in  statu  quo  (as  adult  ichthyosis 
or  xeroderma),  or  showed  an  increase  in  severity  with  advancing  age. 

The  appearances  at  or  soon  after  birth  are  very  characteristic. 
Tiie  subject  has  already  been  called  the  "  collodion  foetus,"  for  the 
whole  Ijody  is  covered  with  a  firm,  dry,  shining,  and  tense  membrane 
("  fest  wie  ein  Trommel,"  says  Behrend  in  the  Berl.  Jdin.  Wchnschr., 
xxii.  88,  1885);  and  M.  Perez  (Froi/res  mdd.,  vii.  524,  1880)  spoke  of 
the  infant  as  covered  by  a  horny  cuirass,  an  "ongle  immense." 
Cracks  and  fissures  traverse  this  collodion-like  covering,  but  are 
generally  quite  superficial.  Soon  after  birth  desquamation  com- 
mences, the  epidermis  being  shed  in  large  yellow  squames,  or  in 
small  fragments  like  films  of  white  tissue  paper.  The  associated 
deformities  of  the  mouth,  nose,  ears,  eyes,  and  limbs  are  evident,  but 
are  never  so  marked  as  in  the  grave  form  of  foetal  ichthyosis. 

The  microscopic  appearances  of  the  skin  have  been  specially 
studied  by  J.  Caspary  (  Vrtljschr.  f.  Dermat.,  xiii.  3,  1886),  and  are 
reproduced  in  Fig.  40.  (Fig.  39,  also  taken  from  Caspary,  is  given 
for  the  sake  of  comparison ;  it  represents  the  skin  of  a  normal  but 
somewhat    atrophic   infant.)     The    skin    has    only  half    the    normal 


31G 


ANTENATAL   PATHOLOCiY   AND    HYCIIKNK 


thickness,  and  tlie  subcutaneous  adipose  tissue  is   also  diininislied ; 
but  tlie  ejiidcrniis  is   relatively  increased,  and  constitutes  fully  one 


:f^:ym^^^,_ : 


■   — -^^rt] 


!h 


Fi«.  39. — Skin  of  Normal  Infant  (Caspary). 

f.  Stratum  corncum  ;  !,  Stratum  lucidum  ;  g,  Stratum  graiuilosum  ;  Sj), 
Stratum  spinosum  ;  ch,  chorium  ;  d.  Sudoriparous  glands  ;  /,  Fat  cells  ; 
m,  Transvei-sely  cut  bundle  of  non-striped  muscular  libres  ;  t,  Sebaceous 
glands ;  v,  Vein. 


FCETAL   ICHTHYOSIS  317 

([uarter  of  tlie  total  skin  thickness.  There  is  no  superficial  fatty 
layer,  and  no  sebaceous  glands  are  to  be  seen ;  and  there  are  only  a 
few  hair  follicles,  but  the  sudoripai'ous  glands  appear  to  be  well 
formed.  All  the  layers  of  the  epidermis  (stratum  corneum,  stratum 
lucidum,  rete  Malpighii,  and  even  the  stratum  granulosum)  are 
thickened.  Caspary's  description  applies  to  an  infant  of  eighteen 
months,  but  in  the  absence  of  observations  on  the  foetus  it  must  be 
taken  as  typical. 


dl. 


d. 


Fig.  40.— Skin  of  Ichthyotic  lufant  (Caspary).     Letters  as  iu  Fig.  39. 

The  same  remarks  apply  to  the  etiology  and  pathogenesis  of  this, 
the  minor  form,  as  to  the  grave  type  of  fcetal  iclithyosis.  Patho- 
logically it  is  ichtliyosis ;  probaljly  it  is  due  to  an  anomaly  in  the 
development  of  the  epitrichium.  It  is  an  interesting  fact  that  a 
typical  case  of  the  disease  with  very  marked  deformity  may  appar- 
ently lie  developed  after  birth,  as  Lang's  case  seems  to  prove  {Berl. 
Idin.  Wchnschr.,  xxii.  819,  1885).  It  would  be  of  the  utmost  value 
if,  in  the  case  of  ichthyosis  developed  iu  childhood,  details  of  the 


318  ANTFAATAL   PATHOLOGY   AM)    HYGIENE 

state  of  the  skin  at  the  time  of  birth  could  always  or  often  be 
obtained.  With  rej^ard,  for  instance,  to  iclithyosis  hystrix  (the  so- 
called  "  porcui)iue  disease  "),  it  is  usually  stated  that  the  disease  was 
not  present  at  birth,  and  it  is  therefore  not  included  amo7if<  the 
fcftiil  diseases ;  but  a  careful  intjuiry  has  in  some  cases  elicited  the 
information  that,  although  the  skin  was  not  ichtliyotic  at  liirth,  neither 
was  it  normal.  For  example,  it  has  sometimes  been  stated  that  at 
l)irth  red  spots,  or  raw-looking  areas,  or  bruises  were  visible  upon  the 
skin  ;  these  have  a  pathological  significance,  and  ought  to  be  inquired 
into. 

Tylosis  Palmae  et  Plantae. 

Under  this  name,  or  under  its  synonym  "  keratoma  plantare  et 
palmare  hereditarium,"  has  been  described  a  congenital  disease 
characterised  by  a  hypertrophy  of  the  horny  layer  of  the  epidermis 
of  the  palms  and  soles  only,  and  not  of  the  general  surface  of  the 
body.  .  The  horny  plate  upon  the  jialms  and  soles  has  a  thickness 
varying  from  one-eighth  to  one-sixteenth  of  an  inch,  and  its  surface  i.s 
cither  smooth  or  pitted.  In  the  case  described  by  the  late  Dr.  George 
Elder  and  myself  (87),  tlie  palmar  plate  had  a  dirty  yellow  colour,  and 
a  hardness  and  roughness  readily  noticed  on  shaking  hands  with  the 
little  patient  (a  girl,  8  years  of  age).  The  thickening  was  greatest  on  the 
hy])othenar  eminences ;  but  it  was  present  also  on  the  thenar  eminences 
and  on  the  palmar  aspect  of  each  finger ;  indeed,  no  part  of  the  palm 
was  quite  free  from  it  except  along  the  lines  of  flexure.  It  did  not,  how- 
ever, reach  the  dorsum  anywhere,  and  it  was  sharply  limited  at  the  line 
of  flexure  of  the  wrist.  Peeling  in  fairly  large  scales  occurred  at  times, 
usually  every  spring  and  autumn.     The  soles  were  similarly  affected. 

In  this  case  (.seen  by  Elder  and  myself)  there  was,  as  has  been  so 
often  found  l;iy  other  writers,  a  distinct  history  of  transmission  from 
ascendants  to  descendants.  The  mother  had  the  same  disease  of  the 
palms  and  soles,  so  had  an  aunt,  and  so  had  the  great-grandmother 
and  her  sister.  In  this  family  tree  all  the  affected  persons  were 
females ;  but  this  is  not  an  invariable  occurrence,  for  in  another 
"  liard-handed  "  family,  one  member  of  whicli  I  have  seen,  the  disease 
was  found  in  males  and  females  in  almost  equal  nundiers.  The  latter 
family  was  that  referred  to  by  Dr.  Allan  Jamieson  at  a  meeting  of 
the  Edinburgh  Medico-C'hirurgical  Society  {Trans.  Med.-Chir.  Soc. 
Edinh.,  n.  s.,  xx.  3,  1901).  Further,  in  Thost's  case  {Dissert.,  Heidel- 
berg, 1880),  in  Vnws!?.  {Vrtljrschr.  f.  DerrnaL,  x.  231,  1883),  in  G.  H. 
Fox's  {Juurn.  Cutan.  and  Vener.  Bis.,  iii.  145,  1885),  in  "W.  Horton 
Date's  {Brit.  Med.  Journ..  p.  718,  ii.  for  1887),  in  Hutchinson's  {Arch. 
Surf/.,  i.  158,  1890;  ii.  74,  1891),  and  in  EadclitTe  Crocker's  {Brit. 
Journ.  Dermat.,  iii.  169,  1891),  many  members  of  the  family  were 
afl'ected,  but  sex  seemed  to  have  ab.solutely  no  determining  iutluence. 
Family  prevalence  and  transmission  from  parents  (or  grand-parents) 
to  children  have  been  more  fre(|uently  recordeil  in  connection  willi 
this  malady,  perhaps,  than  with  almost  any  other;  this  is  a  striking 
fact,  and  must  have  a  meaning.     But  what  ? 

Tylosis  palmaj  has  rarely  if  ever  l)een  observed  at  the  moment  of 


TYLOSIS    I'ALM.E   ET   PLANT.E  319 

birth ;  but  in  some  instances  it  was  noticed  in  tlie  first  week  of  life 
and  became  very  noteworthy  when  friction  began  to  act  on  the  palms 
and  soles.  Probably,  if  these  parts  of  the  body  were  carefully 
scrutinised  at  birtli,  some  slight  morbid  change  would  be  recognised. 
The  lesion  is  usually  painless ;  tactile  sensibility  is  blunted,  as  is 
sensibility  to  heat,  cold,  and  pain ;  there  may  be  either  dryness  or 
increased  secretion  (hyperidrosis). 

According  to  Thost  {o]3.  cit.),  the  microscopic  appearances  are  as 
follows :  "  The  papilUie  are  increased  in  length  five-i'old,  although  their 
breadth  is  somewhat  less  than  uormal ;  the  prickle  cells  are  not 
enlarged  or  altered,  but  are  greath'  increased  in  nimiber,  and  the  rete 
Malpighii  is  on  this  account  much  thicker ;  the  stratum  granulosum 
is  normal ;  the  horny  layer  is  much  thicker,  and  the  cutis  vera  and 
vessels  are  also  somewhat  enlarged." 

In  its  pathology  it  is  probably  more  of  the  nature  of  a  hyperacan- 
thnsis  than  of  a  liyperkeratosis ;  but  all  dermatologists  are  not  agreed 
upon  this  point.  To  solve  the  difficulty  by  calling  it  a  na^vus  is  to 
darken  what  is  already  dark,  for  ntevus  is  not  a  precise  pathological 
term.  Its  pathogenesis  remains  most  obscure.  It  seems  to  require 
intermittent  pressure  after  birth  to  develop  it  fully,  whereas  in  foetal 
ichthyosis  the  thickening  of  the  epidermis  has  occurred  to  its  fullest 
extent  autenatally.  It  is  remarkalily  hereditary,  in  the  usual  sense 
of  the  word ;  and  it  has  been  suggested  that  it  may  be  a  reversion  to 
the  type  of  our  arboreal  ancestors.  The  exact  limitation  of  the  lesion 
is  remarkable ;  and  even  if  the  disease  be  due  to  some  anomaly  in 
the  e]iitrichium,  the  localisation  of  the  anomaly  is  still  imexplained. 

Tlie  malady  does  not  endanger  life,  although  it  may  give,  trouble 
to  the  sensitive  mind ;  and  treatment  has  generally  been  directed 
towards  diminishing  the  disagreeable  roughness  of  tlie  palms  of  the 
hands.  Pumice-stone  has  generally  been  used,  and  some  benefit 
has  resulted  from  painting  the  affected  parts  with  a  solution 
of  salicylic  acid  in  ether. 

FcEtal  Keratolysis. 

In  my  work.  Diseases  of  the  F(etus  (vol.  ii.  188,  1895),  I  have 
descrilied,  under  the  name  of  fcdal  keratolysis,  a  state  of  abnormal 
looseness  of  attachment  or  of  actual  desquamation  of  the  epidermis 
of  the  living  fcetus.  Peeling  of  the  cuticle  normally  occurs  after 
birth,  and  when  it  takes  place  antepartum  it  is  generally  regarded  as 
a  sign  (and  a  sure  sign)  of  fcetal  death  and  commencing  maceration ; 
liut  there  seems  to  lie  no  doubt  that  occasionally  the  living  infant 
comes  into  the  world  with  desquamation  in  full  progress.  I  have 
already  (p.  73)  referred  to  the  exaggeration  of  normal  neonatal 
desc[uamation,  whicli  is  called  keratolysis  neonatorum  or  Eitter's 
disease,  but  in  that  malady  there  is  not  always  reason  to  believe 
that  there  were  any  changes  occurring  antenatally.  In  the  present 
morbid  state  desquamation  is  already  in  active  progress  when  the 
infant  is  born. 

Its   medico-legal   importance    is   very  evident,   for,  as    Dluudell 


320  ANTKNATAL    PATllOLOdV    AM)    IIVCIKNK 

(Obstetric  Medicine,  p.  341,  1840)  puts  it,  "Though  the  desquauiatiou 
of  the  cuticle  is  a  strong  ^»YS(<?/(_/)<('w  argument  in  allirniation  of  the 
death  of  tlie  fa3tus,  it  certainly  is  not  demonstrative,  for  cases  havr 
been  related — and  among  the  rest  one  by  Dr.  Orme — in  which  t\w 
cuticle  has  separated  in  consequence  of  cutaneous  atlcclioiis,  thi' 
cliild  being  alive  notwithstanding." 

I  place  fectal  Ivcratolysis  here  among  the  idiopathic  maladies,  not 
because  1  think  that  it  is  never  the  manifestation  of  a  transmitted 
disease  (e.g.,  measles,  scarlet  fever,  erysipelas,  .syphilis),  Init  simjily  In 
emphasise  the  fact  that  sometimes  no  such  patliogenesis  is  possible. 
Doubtless,  in  some  instances,  it  is  the  evident  sign  of  the  antenatal 
occurrence  of  syphilis  or  of  one  of  tlie  desquamative  exanthemata  : 
but  in  others  a  ditlerent  explanation  has  to  be  souglit.  Thus,  it  is 
sometimes  associated  with  general  anasarca :  in  several  of  the  cases  I 
have  examined  I  liave  noted  this  association,  and  A.  Eibemonl- 
Dessaignes  (Ann.  dc  t/yndc,  xxxii.  8,  1889)  ascribes  it  then  to  rupturr 
of  little  epidermic  vesicles  containing  opalescent  Huid.  In  otlicr 
instances  it  may  be  the  sign  of  foetal  pempliigus,  and  in  several  of 
G.  F.  Cx.  Hueter's  eighteen  cases  (Dissert.,  Marburg,  1858)  it  may 
thus  have  originated ;  in  yet  other  instances  it  may  simply  indicate 
post-maturity  of  the  fcetus  due  to  a  protracted  gestation  of  the 
mother,  as  in  the  observations  of  A.  W.  Edis  (Brit.  Med.  Journ.,  i.  for 
1875,  p.  44),  and  A.  E.  Manby  (ibid.,  ii.  for  1879,  p.  G91).  Finally, 
it  may  be  due  to  some  disturbance  of  the  nutrition  of  the  skin  of  a 
local  kind,  e.g.,  compression  of  a  large  Iilood-vessel  (H.  T.  Hanks, 
Amer.  Journ.  Obst.,  xiii.  595,  1880).  In  Cordon's  observation  (Journ. 
de  nidd.,  chir.,  et  pharm.,  xxv.  556,  17G7)  there  was  family  prevalence, 
three  infants  being  born  with  it  to  the  .same  mother.  C.  L.  Gbckel 
(Miscell.  curios.,  Dec.  ii.,  Ann.  vi.,  obs.  151,  p.  313,  1688),  finding  that 
the  mother  had  suttered  from  malaria  in  pregnancy,  thought  the 
fcetus  had  been  scalded  by  the  hot  liquor  amnii — "  dieses  Kind  isi 
gebrlihet  auf  die  Welt  kommen  "  he  unhesitatingly  averred. 

In  many  of  the  recorded  cases  the  infant  died  soon  after  birth,  but 
in  most  of  Hueter's  observations  it  was  alive  when  the  mother  left 
the  Maternity  Hospital.  In  some  instances  the  desquamation  was 
universal,  affecting  the  wdiole  body  (e.g.,  in  Charrier's  case,  Ga~.  d. 
hop.,  lii.  989,  1879) ;  but  in  most  it  was  more  or  less  localised,  and  it 
is  noteworthy  that  the  localisation  was  not  always  to  the  parts  which 
had  been  subjected  to  pressure  in  labour.  Information  regartling  the 
vernix  caseosa  was  not  always  forthcoming;  in  some  of  Hueter's 
cases  it  was  absent,  but  in  otliers  it  was  copious.  The  desquamation 
itself  was  sometimes  described  as  furfuraceous,  sometimes  as  in  "  large 
flakes  " ;  usually  the  exposed  surface  iiad  a  pale  rose  or  salmon  tint, 
and  not  the  bright  red  colour  seen  in  ])ost-mortem  maceration.  The 
last-named  character  is  not  constantly  distinctive,  and  Schidd  (Arch,  dc 
tocol.  et  dc  gynic.,  xix.  385,  1892)  has  reported  a  case  in  which  both 
varieties  of  desquamation  were  present.  The  postnatal  treatment  will 
consist  in  the  protection  (by  ointments,  vaseline,  cotton-wool,  etc.) 
of  the  denuded  areas  of  skin  from  the  effect  of  cold,  from  irritation, 
and  from  septic  infection.     In  the  absence  of   antenatal  diagnosis. 


HYPERTRICHOSIS   CONGENITA  321 

treatment  before  birth  is  impossible.  The  relation  Ijetween  this 
disease  and  keratolysis  neonatorum,  if  indeed  any  relation  at  all 
exist,  is  not  well  known ;  much  research  is  needed  upon  this  point, 
as  also  in  regard  to  its  bearing  upon  the  normal  desquamation  of 
the  new-born  infant. 

Hypertrichosis  Congenita. 

Hypertrichosis  or  excessive  hairiness  is  a  term  having  a  somewhat 
wide  range  of  application.  The  old  woman  who  develops  scattered 
hairs  upon  the  chin,  and  the  old  man  with  bushy  eyebrows  and  a 
copious  growth  in  the  nostrils,  external  ears,  and  over  the  body,  are 
both  instances  of  hypertrichosis  of  the  senile  type.  The  adult  man 
whose  body,  either  in  a  special  and  unusual  locality  or  over  its  whole 
surface,  is  provided  with  hair,  and  the  adult  woman  whose  hairy 
covering  resembles  in  extent  and  distribution  the  male  type,  are 
examples,  the  one  of  heterotopic,  and  the  other  of  heterogenic 
hypertrichosis.  Further,  at  the  period  of  puberty  the  hair  which 
then  normally  appears  in  both  sexes  may  be  excessive,  and  the  girl  at 
this  time  may  show  the  arrangement  and  development  of  hair  which 
belong  to  the  boy ;  again,  the  appearance  of  the  hair  at  puberty  may 
be  precocious  in  either  sex :  these,  likewise,  are  hypertrichoses. 
There  are  also  hypertrichoses  which  are  due  to  injuries  and  diseases 
of  nerves,  to  trophic  disturbances,  and  to  chronic  inflammatory  states. 
The  nrevus  which  carries  liair  on  its  surface  (n;evus  pilosus)  has  b}' 
some  writers  been  regarded  as  a  hypertrichosis,  but  it  is  advisable  to 
restrict  the  use  of  the  term  to  the  cases  iir  which  the  underlying  skin 
is  apparently  normal.  Finally,  the  infant  at  the  time  of  birth,  or 
very  soon  thereafter,  may  show  a  general  or  a  localised  excessive 
growth  of  hair,  to  which  the  name  of  congenital  hypertrichosis 
(iiniverscdis,  localis)  is  correctly  given.  In  the  other  varieties, 
congenital  predisposition  may,  and  doubtless  does  play  an  important 
part,  but  it  is  with  the  truly  congenital  form  that  we  are  here 
specially  concerned. 

If  Inrth  occur  prematurely,  the  infant  will  show  a  sort  of 
physiological  hypertrichosis  universalis,  for  the  lanugo  of  foetal  life 
will  still  be  present.  This,  however,  is  not  what  is  meant  by  general 
congenital  hypertrichosis,  which  is  rather  the  persistence  till  birth  at 
the  full  time  and  throughout  postnatal  life  of  this  same  lanugo,  more 
or  less  altered  in  its  physical  characters.  It  is  not  yet  definitely 
known  in  what  relation  excessive  hairiness  stands  to  the  foetal 
lanugo,  and  it  is  therefore  not  justifiable  to  define  hypertrichosis  as  a 
persistence  of  the  lanugo.  Accurate  reports  are  much  needed  of  the 
condition  of  the  hair  at  and  immediately  after  birth  in  the  subjects 
of  this  trichogenetic  anomaly ;  doubtless  this  lacuna  in  our  knowledge 
will  ere  long  be  filled,  and  we  shall  then  know  with  some  certainty 
whether  the  lanugo  itself  becomes  the  hair  of  the  "  hairy  infant," 
or  whether  it  falls  off  and  is  replaced  hy  an  entirely  new  growth. 

Various  names  have  Ijeen  given  to  general  congenital  hyper- 
trichosis, among  wliich  are   'polytrichia,  trichauxis,  hirsutics  adnata, 


322 


ANTF-NATAL    I'ATHOLOCiY   AND    HVCIKNK 


dasytcs,  pilosism,  and  hypertrichiasis.  Imlividuals  afi'ected  with  the 
anomaly  in  its  most  marked  form  liave  been  called  "  hairy  men," 
"  homines  pilosi,"  "  human  monkeys,"  "  missinj;  links,"  and  "  Esaus." 
German  equivalents  are  "  Haarmenschen,"  "  Waldnienschen,"  and 
"  Hundemenschen  " ;  and  in  French  the  expressions  "  les  hommes 
veins,"  "  les  hommes  des  hois,"  and  "  les  hommes-chiens  "  are  met  with. 
Cases  of  general  hypertrichosis  congenita  are  rare.  The  first 
recorded  case  seems  to  have  been  that  of  Esau,  who  "  came  out  red 
all  over  like  a  hairy  garment"  (Gcni'sis  xxv.  2:'i),  or  moi'c  literally 
"all   of  him  as  a  cloak  of  hair."     The  meaning  of  this  hairy  liirtli 


has  greatly  puzzled  the  commentators,  and  Kalisch  iminti'il  tn  it  as  "a 
foreboding  of  the  animal  violence  of  Esau's  character."  In  the  ^Middle 
Ages  there  was  a  difference  of  opinion  also  as  to  whether  or  not  Esau's 
state  constituted  a  monstrosity,  and  Pohlius,  in  1669,  wrote  a  work 
with  the  interrogative  title, "  De  Questione  an  Esau  fuerit  ^lonstrum." 
Among  other  historical  examples  was  the  girl  born  near  I'isa,  hairy 
all  over  ("  totam  hirsutam  "),  whose  mother  had  been  gazing  at  a 
picture  of  John  the  Baptist  during  her  pregnancy  {vide  T.  Fienus,  Be 
Tiribus  iraayi nation  in,  j).  224,  16:!r)):  and  there  was  the  hairy  child 
belonging  to  the  Ursini  faiuily,  who  had  bear'.s  claws  as  well  as  the 
hirsute  covering.     There  was  the  remarkable  hairy  family  ('  homines 


hypp:rtrichosis  congenita  323 

sylvestres  ")  from  the  Canary  Islands  described  by  U.  Aldrovandiis 
(Monstrorum  Histona,  p.  16,  1G42);  and  there  was  also  "Die  haarige 
Fauiilie  von  Ambras,"  consisting  of  a  hairy  man,  his  wife  normal  in 
the  matter  of  hair,  and  his  hairy  son  and  daughter  (Figs.  41-44), 
described  fully  by  C.  T.  von  Siebold  {Arch.  f.  Anthrop.,  ix.  253, 
1877-8).  Another  well-known  example  of  hypertrichosis  was 
"Barbara  Ursler,"who  was  publicly  exhibited  in  London  in  1655,  and 
who  is  described  in  Caultield's  Portraits,  Memoirs,  unci  Charc(cters 
(vol.  ii.  p.  168,  London,  1794-5),  and  has  been  recently  considered 
by  Strieker  {Arch.  f.  path.  Anat.,  Ixxi.  p.  Ill,  1877).  John 
Crawford,  who  studied  medicine  in  the  University  of  Edinburgh  in 
the  early  years  of  the  past  century,  and  who  was  afterwards  envoy 
to  the  Court  of  Ava,  brought  before  the  notice  of  European  authors 
the  famous  hairy  family  of  Burma  {Journal  of  Embassy  to  the  Court 
of  Ara,  London,  1834);  and  many  others  have  since  contributed 
details  regarding  this  family.  It  consisted  of  a  hairy  man  married 
to  a  normal  woman,  of  his  hairy  daughter,  and  of  two  hairy  grandsons 
the  children  of  the  daughter  by  a  normal  man ;  the  dentition  of  these 
individuals  seems  to  have  been  defective  {vide  J.  J.  Weir,  Nature, 
xxxiv.  223,  1886).  Eeference  must  also  be  made  to  the  hairy 
Mexican  woman,  Julia  Pastrana,  described  by  J.  Z.  Lawrence  {Lancet, 
ii.  for  1857,  p.  48),  H.  Beigel  {Arch,  f  path.  Anat.,  xliv.  418,  1868), 
F.  L.  Neugebauer  {Kilka  sloiv  o  mczldem  owlosicniu  u  Kobict,  1897), 
and  by  J.  Eanke  ( Verhancll.  d.  Miinchen.  anthropi.  Gcsellsch.,  1-4, 
1888) ;  she  seems  to  have  had  hypertrophy  of  the  maxilla  (E. 
Magitot,  Gaz.  med.  de  Paris,  4  s.,  ii.  609,  1873).  In  Chowne's  case 
{Lancet,!,  for  1852,  pp.  421,  514;  ii.  for  1852,  p.  51)  the  hamness 
was  widespread  although  hardly  universal;  the  patient,  a  woman, 
had  a  hairless  brother  and  one  hairy  sister  (Wilson,  Lectures  on 
Dermatology,  p.  102,  1878).  The  girl  Teresa  Gambardella,  described 
by  C.  Lombroso  {L'uomo  hicnieo  e  I'uomo  di  colore,  p.  155,  1871), 
resembled  Chowne's  patient  to  a  certain  degree.  Then  there  were 
the  famous  Russian  "  hairy  men  "  or  the  "  Kostroma  people  "  described 
and  discussed  by  many  authorities  (E.  E.  Perrin,  B%dl.  Soc.  d'anthrop. 
de  Paris,  2  s.,  viii.  741,  1873 ;  C.  Eoyer,  ibid.,  p.  718 ;  C.  S.  Tomes, 
Brit.  Med.  Journ.,  i.  for  1874,  p.  413 ;  E.  Virchow,  Berl.  Uin. 
Wchnsehr.,  x.  337,  1873 ;  G.  T.  Jackson,  Med.  Record,  New  York, 
xxvii.  568,  1885 ;  and  A.  Ecker  Gratidationssc.hrift,  Braunschweig, 
1878) ;  these  two  men  (father  and  son  ?)  had  a  very  remarkable 
skye-terrier  appearance,  they  were  both  nearly  edentulous,  and  their 
nails  were  soft  and  thin  (J.  VnvveiAi,  Deutsche  Monatsschr.  f.  Zalinhlk., 
iv.  H.  2,  1886).  Finally,  among  the  well-known  instances  of  hyper- 
trichosis, there  was  Krao,  "  the  missing  link,"  who  was  seven  years 
old  when  she  was  exhibited  by  Farini  in  London  in  1883.  When 
seen  by  A.  H.  Keane  {Kcdure,  xxvii.  245, 1882—3),  she  was  of  average 
intelligence,  her  face  and  low  forehead  were  covered  down  to  the 
bushy  eyelirows  with  deep  black,  lank,  and  lustreless  hair,  Mongoloid 
in  type ;  her  whole  body  was  overgrown  with  a  less  dense  coating 
of  soft  black  hair ;  the  skin  beneath  was  dark  olive  brown ;  the  feet 
were  prehensile,  and  the  hands  could  be  bent  back  at  the  wrists ;  and 


324  ANTENATAL   PATHOLOGY   AND    HYCJIENK 

there  was  slight  prognathism.  She  was  said  to  he  tlie  chikl  of 
Siamese  parents  {Nature,  xxvii.  579,  1882-3).  Fauvelle  (7/^///.  de  In 
Soc.  d'anthrop.  de  Paris,  ?>  s.,  ix.  439,  1886),  writing  in  1880,  wln-n 
Krao  was  about  eleven  years  old,  found  the  second  dentition  complete, 
save  that  the  upper  canines  had  not  yet  been  cut. 

From  the  preceding  summary  of  the  best  known  of  the  recorded 
cases  of  congenital  hypertrichosis,  certain  outstanding  characters 
in  the  clinical  history  and  syiivptomatology  will  lia\e  been  recognised. 
Heredity  has  lieen  very  evidently  present  in  several  cases,  as  in  the 
von  Anibras  Family  and  the  Hairy  Family  of  Burma ;  family 
prevalence,  also,  was  noted  in  several  instances.  In  two  cases 
reported  by  P.  Michelson  {Arch.  f.  pnth.  Anal.,  c.  66,  1885)  these 
chai-acters  were  also  present:  in  one,  the  hairiness  affected  a  man, 
(Joseph  Fieber),  a  native  of  Silesia,  his  eldest  daughter,  his  mother, 
and  two  brothers ;  in  the  other,  the  father  was  the  subject  of  hyper- 
trichosis, and  so  were  two  of  his  sons.  In  both  of  Michelson's  family 
histories  defective  dentition  was  present,  and  it  was  sometimes 
transmitted  along  with  the  hirsuties  and  sometimes  apart  from  it. 
The  sisters  Francina  and  Fytje  1*.,  described  by  Cleyl  {liiol.  Ccniralbl., 
viii.  332, 1888-9),  were  examples  of  the  minor  degree  of  hypertrichosis 
universalis.  Lina  Naumann,  the  hairy  girl,  seen  by  L.  Fiirst  {Arch, 
f.  path.  Anat.,  xcvi.  357,  1884),  was,  however,  an  exception  to  the 
above  rule,  for  she  was  apparently  the  only  member  of  her  family 
affected ;  but  she  resembled  Krao  and  Julia  I'astrana  in  the 
possession  of  normal  teeth  set  on  hypertrojihied  alveolar  margins. 
Marietta  S.,  also,  reported  by  C  Hennig  {Jahrh.  f.  Kinderhlk.,  xl. 
107,  1895),  seems  to  have  been  a  solitaiy  instance  of  hypertrichosis; 
but  from  the  description  it  would  appear  to  have  been  a  case 
complicated  with  ntevus  pilosus. 

Details  of  the  state  of  the  hairy  infants  at  birth  are  sadly  lacking. 
In  Geyl's  two  patients(/oc.f(Y.), marked  hair  on  the  scalp  and  long  lanugo 
on  the  forehead  and  cheeks  were  present  at  birth,  but  at  the  age 
of  two  and  a  half  years  there  was  a  sudden  increase  in  the  hair  over 
the  limbs  and  body.  In  Ftirst's  patient  {loc.  cit.)  the  abnormal  hairi- 
ness of  the  body  was  clearly  visible  within  the  first  week  of  life,  and 
bushy  eyebrows  were  noticed  at  birth.  In  the  "homo  hirsutus" 
described  by  Krebs  {Hosp.-Tid.,  2  E.,  v.  609,  1878)  the  excessive 
hairiness  did  not  appear  until  the  third  month  of  life.  It  was  usually 
found  that  the  face  and  hands  were  specially  hairy,  and  this  gave  a 
very  characteristic  animal  appearance  to  many  of  the  indiviiluals ; 
but  in  I'ickells'  patient  {Edinh.  Med.  and  Sury.  Journ.,  Ixxvi.  316, 
1851)  the  face  and  hands  were  free,  wliile  the  rest  of  the  body  was 
hairy.  In  some,  the  hair  was  very  coarse,  but  in  others  it  was  soft 
and  silky ;  usually  it  followed  the  lines  of  direction  taken  by  the 
lanugo  in  foetal  life.  The  hypertrichotic  condition  apparently  did 
not  interfere  with  postnatal  existence  in  any  of  the  recorded  cases, 
and  it  was  not  associated  with  sterility.  There  was  sometimes  a 
correlative  variability  seen  in  the  dental  development,  and  reference 
has  been  made  to  the  alveolar  hypertrophy  in  Julia  Pastrana  and 
others ;  but  sometimes  there  was  apparently  compensatory  defective 


HYPERTRICHOSIS   CONGENITA  325 

development  of  the  teeth,  as  in  the  Eussian  "  hairy  men."  It  may  be 
noted  here  that  congenital  alopecia  has  also  been  found  associated 
with  dental  defects  (vide  infra),  and  Magitot  (loc.  cit.)  has  referred  to 
it  both  in  hairless  men  and  in  the  hairless  Chinese  dogs.  The  Ainos 
of  Japan  are  distinguished  from  Mongolian  and  Japanese  peoples  by 
a  sort  of  racial  hypertrichosis ;  they  also  show  a  marked  development 
of  the  alveolar  border  of  the  superior  maxilla  with  consequent  prog- 
nathism (Ashmead,  Sci-i-hicai  Med.  Journ.,  xiv.  183,  1895). 

The  pathogenesis  of  hypertrichosis  congenita  is  closely  beset  with 
problems.  There  seems  to  be  something  paradoxical  in  the  idea  that 
this  excessive  production  of  hair  is  an  arrested  development ;  but  on 
examination  it  would  appear  that  the  theory  of  an  arrest  is  better 
supported  by  facts  than  any  other.  The  persistence  of  the  lanugo  is 
undoubtedly  of  the  nature  of  an  arrested  development,  for  normally 
it  is  shed  before  or  soon  after  birth.  But  is  hypertrichosis  a  per- 
sistence of  the  lanugo  ?  In  order  to  answer  this  question,  it  would 
be  necessary  to  have  a  knowledge  of  the  state  of  the  hair  in  "  hairy 
infants "  dviring  tlie  first  hours  of  life,  and  more  especially  of  its 
microscopical  characters ;  this  knowledge  is  not  yet  in  our  possession. 
We  do  not  know  whether  in  these  cases  a  casting  of  the  hair  occurs 
at  birth  or  not.  As  has  been  pointed  out  by  P.  G.  Unna  {Histojjath- 
ology  of  the  Skin,  N.  Walker's  Transl.,  p.  1151,  1896),  if  the  former 
be  the  case,  and  if  the  embryonic  hair  follicles,  instead  of  becoming 
shorter  all  over  the  body  at  this  period  of  life,  retained  their  double 
length,  then,  in  spite  of  the  abundance  of  hair,  it  is  justifiable  to  speak 
of  hypertrichosis  as  an  arrested  development.  But  if  on  the  trunk  and 
limbs  the  ordinary  casting  of  the  hau-  had  taken  place  in  utero  and 
all  the  hair  follicles  had  shortened,  and  if,  later,  these  follicles  had  (as 
occurs  normally  on  the  scalp)  again  expanded  to  the  original  (doulde) 
length,  and  so  given  rise  to  another  and  a  very  strong  growth  of  hair, 
then  the  condition  would  Ije  that  of  a  true  hypertrichosis,  analogous 
to  the  hypertrichosis  of  puberty.  Unna  is  of  opinion  that  both  these 
possibilities  may  occur,  and  that  while  for  instance  the  former  view 
holds  with  regard  to  the  Eussian  "  hairy  men,"  the  latter  explains 
such  cases  as  Krao  and  Julia  Pastrana ;  he  prefers  to  call  the  former 
(the  simple  persistence  of  the  foetal  hair)  "  trichostasis "  or  "  hair- 
stagnation,"  while  the  latter  is  true  hypertrichosis.  It  is  easy  to 
exaggerate,  as  I  think  Unna  does,  the  difficulty  of  accepting  the  theory 
of  an  arrest  of  development ;  congenital  ichthyosis  also  is  characterised 
by  excessive  growth  (of  the  stratum  corneum),  and  this  is  probably 
due  to  an  anomaly  of  the  epitrichium,  likewise  an  arrest  of  develop- 
ment. If  the  theory  1  le  correct,  then  in  some  instances  hypertrichosis 
is  truly  a  monstrosity  rather  than  a  disease,  while  in  others  it  is  more 
correctly  a  disease ;  so  that  after  more  than  two  hundred  years  we 
might  write  again  as  Pohlius  did  in  1669,  "  De  questione  an  Esau 
fuerit  monstrum."  In  a  similar  unsettled  state  we  must  leave  the 
question  of  the  atavistic  nature  of  congenital  hypertrichosis. 

No  treatment  has  been  proposed  or  indeed  thought  of  for  general 
hypertrichosis ;  but,  for  the  localised  form,  electricity  and  the  Etintgen 
rays  have  been  employed  for  cosmetic  purposes.     The  localised  form. 


326  AN'TKNATAL    I'A  rilOLOCY    AND    HVdIF.NK 

it  may  be  remarked,  lias  usually  Ijeeu  confounded  witii  hairy  lucvus 
(iKL'Vus  jiilosus):  Imt  it  ou^ht  to  he  distiiif^uished  from  it,  for  in  true 
hyperlririmsis  tlie  underlying  skin  ought  neither  to  be  ]»igmented 
nor  abnormally  vascular.  No  doubt  most  of  the  cjises  of  "  bearded 
infants  "and  babies  born  with  hairy  "  tails"  have  been  instances  of 
niTiVus  afiecting  tlie  face  or  sacral  region,  and  the  so-called  "  bathing 
drawers  "  usvus  is  a  well-known  variety  of  cutaneous  ])igmentation ; 
but  true  cases  of  hypertrichosis  localis  occur,  although  rarely.  For 
instance,  there  was  A.  H.  Dodd's  ca.se  of  lumliar  hypcrtricliosis 
(ZaH«'<,  ii.  for  1887,  p.  10G;3),  and  there  was  also  Balmanno  Squire's 
(Brit.  Med.  Journ.,  i.  for  1893,  ]>.  1265),  in  which  a  patch  (jf  long  hair 
was  present  on  the  side  of  the  neck.  L.  A.  I'arry  (Lanai,  i.  for 
1896,  p.  1717)  recorded  a  case  of  lumbar  hairiness  afiecting  two 
sisters.  The  so-called  "  lady  with  the  horse  mane "  was  a  case  of 
hypertrichosis  localised  in  the  dorsal  region ;  in  this  case  there  was  a 
defect  in  the  vertebral  column  (spina  bifida  occulta)  underlying  the 
hair.  This  association  of  lumbar  hypertrichosis  with  spina  bifida 
occulta  has  been  noted  by  se\'eral  observers  in  other  cases,  e.;/., 
by  W.  Strieker  (Arrh.  f.  ixdh.  Anat.,  l.xxiii.  624,  1878),  by  F.  von 
Kecklinghausen  (ibid.,  cv.  pp.  243,  373,  1886),  by  C.  Brunner  (ibid., 
cvii.  494,  1887),  by  G.  Joachimsthal  (ibid.,  cxxxi.  488,  1893), 
and  by  others.  In  some  of  these  instances  there  was  a  further 
complication  which  came  on  in  later  life,  namely,  perforating  ulcer  of 
the  foot.  Some  of  the  cases  reported  as  infants  with  tails  were  no 
doubt  instances  of  lumbar  hypertrichosis.  Bland  Sutton  (Lancet,  ii. 
for  1887,  p.  4)  wrote  suggestively  on  this  subject,  as  did  also  Emil 
Kruska  (I)isscrt.,  Jena,  1890). 

Congenital  Alopecia  (Hypotrichosis). 

It  is  well  known  that  early  baldness  (alopecia  prematura)  is 
hei'editary  in  some  families;  but  true  congenital  alopecia,  or  the 
absence  of  hair  at  birth,  is  very  rare.  When  this  amunaly  is  met 
with,  it  is  usually  stated,  as  in  J.  B.  Luce's  case  (These,  Paris,  1879), 
that  the  infant  is  hairless  at  Ijirth,  and  remains  so  for  months  or  even 
j'ears,  but  that  ultimately  a  certain  degree  of  hairmess  is  attained. 
P.  de  Molenes  (Aim.  de  deriiuxt.  ct  sypk,  3  s.,  i.  548,  1890)  also  re- 
ported a  case  in  which  at  birth  there  were  only  a  few  downy  hairs  on 
the  scalp  and  a  few  eyelashes ;  some  years  pre^■iously  the  mother  had 
suffered  from  alopecia,  and  she  had  given  birth  to  another  child  who 
had  developed  alopecia  of  the  scalp  some  time  after  birth  ;  the  present 
child,  a  female,  had  normal  nails,  and  the  first  dentition  ju-ogressed  in 
the  usual  manner ;  under  treatment,  hair  began  to  appear  at  the  age 
of  four  years.  The  author  regarded  the  alopecia  as  a  trophoneurosis, 
and  from  the  standiwint  of  Antenatal  Pathology  we  may  look  upon 
such  cases  as  instances  of  delayed  sprouting  of  the  hair.  In  another 
group  of  cases  the  congenital  alopecia  persists  throughout  life.  This 
was  apparently  the  condition  of  afl'airs  in  M.  Schedc's  two  ])atients,  a 
brother  and  a  sister  (Air/i.f.  klin.  C/iir.,  xiv.  158,  1S72),  who.se  heads 
were  as  smooth  as  a  billiard-ball  ("  wie  eine  Billardkugel ") ;   hair 


CONGENITAL   ALOPECIA  327 

rudiments  were  found  only  in  the  deep  layers  of  the  cutis.  Possiljly 
this  was  also  the  case  in  the  Australian  hairless  individuals  (brother 
and  sister)  described  by  N.  iliklucho-Maclay  {Vcrhandl.  d.  Berlin. 
Gesellsch.  f.  Anthrop.,  p.  143,  1881).  In  yet  another  group  of  cases 
the  alopecia  is  associated  witli  defective  dentition  and  nail-formation 
(J.  Thuruam,  Mcd.-Chir.  Trans.  Lond.,  xxxi.  71,  1848).  Several 
instances  of  this  type  are  referred  to  by  E.  Bonnet  {Uhcr  Hypo- 
trichdsis  congenita  universalis,  Wiesbaden,  1892),  who  also  mentions 
examples  in  the  lower  animals.  It  would  appear  to  be  transmitted 
by  heredity  (J.  Hutchinson,  Arch.  Surf/.,  ii.  253,  1891).  Perspiration 
may  also  be  entirely  absent. 

It  is  quite  evident  that  coiij^enital  alopecia  is  an  arrested  develop- 
ment, and  its  association  with  defective  formation  of  the  nails  and 
teeth  emphasises  and  confirms  this  conclusion.  Evidently  the  arrest 
may  neither  be  complete  nor  permanent,  and  in  this  manner  are  pro- 
duced the  -various  types  which  have  been  described  above.  Treat- 
ment with  stimidating  applications  and  perhaps  thyroid  extract 
ought,  therefore,  to  be  persisted  in,  for  it  maj"  be  ultimately  rewarded 
b}*  success.  Antisyphilitic  treatment  ought  also  to  be  tried,  as 
alopecia  may  he  due  to  syphilis. 

Like  hypertrichosis,  alopecia  is  a  malformation  rather  than  a 
disease  ;  and  with  it  as  with  hypertrichosis  the  question  at  once  arises 
if  it  can  at  all  be  regarded  as  idiopathic,  since  it  seems  in  some  cases 
to  be  hereditarily  transmitted  and  to  sliow  family  prevalence.  I  do 
not  attempt  to  justify  the  inclusion  of  these  two  morbid  states  in  the 
group  of  the  idiopathic  diseases  of  the  fcetus ;  but  I  repeat  that  I 
regard  the  group  as  a  convenience  rather  than  as  an  expression  of 
strict  classification.  Further,  there  are  many  cases  in  which  no 
heredity  can  be  traced. 

Antenatal  Pemphigus. 

In  1891,  Bar  (Arch,  de  tocoL,  xviii.  953,  1891)  met  with  a  case  of 
pemphigus  in  an  infant  at  birth  ;  there  were  also  patches  of  denuded 
skin  on  the  scalp,  and  he  suggested  that  in  some  instances  the 
hairless  areas  of  alopecia  might  be  looked  upon  as  the  final  stage  in 
the  development  of  the  bulla;  of  pemphigus.  Wliether  this  supposi- 
tion prove  to  be  right  or  wrong,  there  can  be  no  doubt  that  in  certain 
eases  pemphigus  affects  the  foetus.  I  have  already  (p.  74)  referred 
to  the  occurrence  of  pemphigus  in  the  new-born  infant,  in  whom  it 
may  be  due  to  syphilis  or  to  some  septic  or  infectious  condition ;  but 
there  are  also  instances  in  which  the  child  is  liorn  with  a  strongly 
marked  and  often  a  transmitted  tendency  to  form  bullffi  on  the  slightest 
provocation,  e.g.,  a  slight  blow.  In  these  cases  the  tendencj'  is 
doubtless  present  in  antenatal  life,  although  sometimes  no  bullous 
formations  are  noticed  till  the  second  week  of  life.  It  has  been 
proposed  to  separate  this  morbid  tendency  from  ordinary  pemphigus 
neonatorum,  to  call  it  "  congenital  traumatic  pemphigus,"  or  to  give 
to  it  such  names  as  "  epidermolysis  bullosa,"  "  congenital  bullous 
dermatitis,"  and  "  hereditary  dermatitis  bullosa  " ;  further,  attempts 


328  ANTENATAL   PATHOLOGY   AND    HYGIKNK 

have  also  been  made  to  separate  two  sub-varieties,  under  the  designa- 
tions of  "  bullous  dermatosis  "  and  "  epidermolysis  bullosa  " ;  but 
it  is  generally  agreed  that  in  the  present  state  of  our  knowledge 
dermatologists  are  not  warranted  in  making  these  distinctions. 
There  is  in  all  the  cases  a  constant  tendency  to  form  YmWx  (con- 
taining blood  or  serum)  after  the  most  insignificant  traumatism  :  this 
tendency  is  noted  at  or  very  soon  after  birth ;  the  general  health  is 
unaffected ;  sometimes  the  malady  tends  to  disappear,  sometimes  it 
is  accompanied  by  the  formation  of  epidermic  cysts ;  and  often  there 
is  a  distinct  history  of  heredity  and  family  prevalence.  The  nails 
are  often  defective.  A  ccmsiderable  number  of  articles  have  appeared 
dealing  with  this  disease,  among  which  I  may  mention  those  of 
Tilbury  Fox  (Lancet,  i.  for  1879,  p.  776),  A.  Goldscheider  {Monatsh. 
f.  frald.  Dermat.,  i.  163,  1882),  A.  Valentin  {Bni.  /din.  Wchnschr., 
xxii.  150,  1885),  Max  Joseph  {Monatsh.  f.  praJd.  Dermat.,  v.  5,  1886), 
Carl  Blumer  {Dissert.,  Ziirich,  1892),  H.  Hallopeau  {Ann.  de  dermat. 
et  syph.,  3  s.,  vii.  453,  1890),  M.  V.  Augagneur  {ihid.,  viii.  665,  1897), 
Wallace  Beatty  {Brit.  Journ.  Dermat.,  ix.  301,  1897),  T.  Colcott  Fox 
{ibid.,  ix.  341,  1897),  and  John  T.  Bowen  {Journ.  Cutan.  Gen.-Urin. 
Dis.,  xvi.  253,  1898).  Little  is  known  of  the  pathology  of  the 
aflection,  and  much  less  of  its  pathogenesis ;  to  describe  it  as  an 
angiotic  acantholysis  does  not  add  much  to  our  knowledge  of  its 
exact  nature.  TJie  antenatal  factor,  however,  is  an  important  one, 
and  possibly  when  the  mechanism  of  neonatal  desquamation  is  lietter 
understood,  so  will  also  that  of  hereditary  bullous  formation.  Blumer 
{op.  cit.)  compared  the  disease  with  haemophilia:  both  maladies  are 
congenital  and  inherited,  and  due  to  a  defective  formation  of  the 
blood  vessels  which  may  1)e  termed  "  dysplasia  vasorum " ;  in 
hfemophilia  bleeding  occurs,  in  epidermolysis  exudation.  According 
to  Wallace  Beatty  {loc.  cit.),  who.se  paper  contains  many  bibliographical 
references,  the  bulhe  may  form  either  in  the  stratum  corneum  or 
may  involve  the  rete  mucosum  also.  Drugs  or  other  treatment 
have  hitherto  been  powerless  to  influence  the  progress  of  the  disease, 
but  chloride  of  calcium  might  be  tried  autenatally  as  well  as 
postnatally. 

Congenital  Absence  of  Skin. 

In  Marcli  1859,  W.  0.  Priestley  {Trans.  Obst.  Soc.  land.,  i.  60, 
1860)  exhibited  a  drawing  taken  from  the  head  of  a  new-born  child, 
which  showed  a  curious  "  circular  wound  "  of  antenatal  origin.  It 
was  quite  circular,  was  as  large  as  a  shilling,  and  was  situated 
directly  over  the  posterior  fontanelle.  It  seemed  as  if  "  a  piece  of  the 
scalp  had  lieen  jiunched  out  by  a  circular  instrument."  The  process 
of  repair  liail  begun,  the  edges  of  the  wound  were  still  sharply 
defined,  and  its  floor  was  formed  by  the  pericranium  with  its  supjily 
of  delicate  capillaries.  The  cranial  bones  were  entire  and  of  their 
usual  form.  The  child  was  well  formed,  there  were  no  skin  eruptions, 
and  a  profusion  of  dark  hair  covered  the  head  except  in  the  above- 
mentioned  circular  patch.     There  was  no  history  of  syphilis,  and  the 


CONGENITAL   ABSENCE   OF   SKIN  329 

labour  (the  mother's  third)  had  been  comparatively  easy.  In  1880, 
Hans  von  Hebra  {Mitth.  a.  d.  embryol.  Inst.  d.  k.  k.  Univ.  in  Wien.,  ii. 
85,  1880-83)  described  a  somewhat  similar  case,  in  which  the 
cutaneous  defect  was  also  on  the  scalp  but  was  bilateral  and  had  a 
more  elongated  and  irregular  form.  These  patches,  reaching  from 
the  outer  angle  of  the  eye  outwards  and  upwards,  had  a  reddish- 
yellow  colour  and  carried  no  hairs ;  they  were  thus  easily  distinguish- 
able from  the  surrounding  scalp,  which  was  covered  with  long  hairs. 
The  parents  were  healthy  and  the  labour  had  been  normal.  The 
bones  of  the  head  showed  no  defects,  and  there  were  no  signs  of 
pemphigus  or  any  other  skin  disease.  The  child  died  when  five 
days  old  from  peritonitis.  The  microscopical  appearances  showed  a 
real  defect  in  the  development  of  all  the  layers  of  the  epidermis  and 
of  the  associated  glands,  fat,  and  hairs ;  the  surrounding  normal  skin 
was  sharply  marked  off  from  the  defect.  In  neither  of  these  cases 
were  details  regarding  the  placenta  and  membranes  given.  A  third 
case  resembling  those  already  described  was  put  on  record  in  1894 
by  V.  W.  Matthes  {Dissert.,  Marburg). 

An  earlier  observation  than  any  of  these,  seems,  however,  to  have 
been  that  of  W.  Campbell  of  Edinburgh  {Edin.  Jo^irn.  of  Med.  Sc, 
ii,  82, 1826)  who,  under  the  title  of  "  Congenite  Ulcer  on  the  Cranium 
of  a  Fetus,"  described  a  case  in  which  there  was  an  area  without  skin 
about  the  size  of  a  crown-piece  situated  between  the  bregma  and  the 
posterior  fontanelle ;  bleeding  from  this  denuded  area  took  place, 
proving  fatal,  on  the  eighteenth  day  of  life.  Curiously  enough,  the 
mother  of  this  child  in  her  next  pregnancy  gave  birth  to  another 
infant  with  a  similar  spot  on  the  scalp,  but  in  this  instance  cicatrisa- 
tion had  begun  in  utero.     The  labour  was  easy  and  natural. 

These  cutaneous  defects,  however,  are  not  always  localised  on  the 
scalp,  for  Hochstetter  {Charift'-Ann.,  Jahrg.  xix.  542,  1894)  met 
with  the  case  of  a  full-time  male  foetus  with  patches  on  each  side  of 
the  abdomen,  a  little  above  the  level  of  the  umbilicus ;  these  were 
somewhat  triangular  scars  which  had  been  bright  red  at  birth  ;  there 
was  club-foot  on  the  left  side ;  and  the  placenta  and  membranes  were 
said  to  be  normal.  Other  cases  were  that  i-eported  by  B.  S.  Schultze 
(Ztschr.  f.  Gehurtsh.  u.  Gyndk.,  xxxi.  225,  1895),  in  which  there  was 
also  paralysis  of  the  right  facial  nerve  and  contracture  of  the  right 
sternomastoid  muscle;  that  seen  by  Hugo  Goldberger  (Centralbl.  f. 
Gyndk.,  xx.  784,  1896),  in  which  the  infant  was  one  of  twins,  the 
other  twin  being  a  foetus  papyraceus ;  and  that  recorded  by  F. 
Ahlfeld  (Erne  neuc  typische  Form  dnrcli  amniotische  Fdden  hervonjc- 
hrachter  Verhildung,  Wien,  1894),  who  regarded  the  defect  as  due 
to  the  tearing  through  of  an  amniotic  adhesion.  Ahlfeld  referred 
also  to  cases  by  Dohrn  [Ztschr.  f.  Gehurtsh.  u.  Gyndk.,  xiv.  366,  1888) 
and  R.  von  Braun  {Ccntratbl.  f.  Gyndk.,  xviii.  73,  1894),  in  the 
latter  of  which  the  cutaneous  defect  was  situated  on  the  knees. 

In  some  instances  the  skin  defect  was  associated  with  other 
malformations,  e.g.  Polydactyly,  and  this  fact  seemed  to  Ahlfeld  to 
support  his  theory  of  the  amniotic  origin  of  these  denuded  areas. 
We  must  imagine  the  existence  of  a  tubular  adhesion  between  the 


330  AN  rKNATAI,    I'ATHOLOdY    AND    IIY(;IF.NK 

amnion  ;uul  the  skin  surface;  if  this  is  turn  across  near  the  skin, 
the  resulting,'  alisence  of  tlie  superticial  layers  of  tlie  inte<,nnncnt  will 
be  produced.  The  whole  question  of  amniotic  iniiuence  will  recjuire 
consideration  under  the  headinj^  of  Teratogenesis,  but  in  the  mean- 
time it  may  be  noted  that  the  recorded  absence  of  any  gross  altera- 
tions in  the  jilaceuta  and  membranes  does  not  exclude  the  possibility 
of  the  existence  of  amniotic  adhesions.  At  first,  the  anniion  is  in 
contact  with  the  surface  of  the  eudjryo  in  its  whole  extent ;  normally 
it  separates  everywhere  from  it  as  the  liquor  amnii  is  secreted  ;  but, 
inider  some  circumstances,  this  separation  docs  not  take  place  per- 
fectly, and  the  attached  amnion  is  drawn  out  into  a  band,  a  so-called 
amniotic  adhesion.  The  tearing  across  of  this  "  adhesion "  would 
give  rise  to  a  raw  area  if  the  tear  be  close  to  the  skin.  If,  on  the 
other  hand,  the  tearing  across  be  at  some  distance  from  the  skin,  the 
result  may  be  a  small  projection  which  might  be  called  an  amniotic 
appendage  or  j)erhaps  an  amnioma.  In  a  case  reported  by  J. 
Dalston  Jones  (Trans.  Mrd.-L'hir.  Soc.  Land.,  2  s.,  xiv.  ]i.  59,  18-49),  a 
cutaneous  defect  and  a  nipple-like  projection  existed  side  by  side. 
Such  an  appendage  or  nip]ile-like  process  was,  I  believe,  the  congenital 
growth  which  I  described  some  years  ago  as  an  acanthoma  of  the 
hairy  scalp  (98).  With  its  description  I  may  close  this  chapter  on 
Tcetal  Diseases  of  the  Skin. 

Acanthoma  or  Amnioma  of  the  Skin. 

In  October  1896,  one  of  my  midwifery  students  at  the  Western 
Dispensary,  Edinburgh,  informed  me  that  he  had  been  mnch  puzzled 
to  make  out  the  fcetal  presentation  in  a  case  of  labour  attended  by 
him  on  the  previous  day.  His  first  diagnosis  of  a  vertex  presenta- 
tion had  been  weakened  by  the  detection  of  a  finger-like  projection 
attached  to  the  presenting  part.  He  was  not  long  in  dinibt,  however, 
for  the  labour  terminated  speedily  and  naturally ;  it  was  then  seen 
that  the  vertex  certainly  had  presented,  l)ut  that  tliere  was  also  a 
congenital  growth  attached  thereto,  and  it  was  this  that  had  sinm- 
lated  the  presence  of  a  finger.  It  may  be  said  that  the  infant,  a  girl, 
was  the  ninth  child  of  a  healthy  mother,  aged  34  years.  There  were 
eight  brothers  and  sisters,  some  of  whom  were  rachitic,  and  all  the 
nine  children  had  been  born  within  twehe  j'ears.  The  present  preg- 
nancy had  been  quite  uneventful;  even  the  ubiquitous  and  popularly 
omnipotent  maternal  imjuessiou  was  wanting.  The  chilil  showed  no 
other  malformations,  and  there  was  no  family  history  of  deformity. 
The  tumour  showed  some  tendency  to  wither;  but  in  three  weeks  I 
excised  it,  as  the  mother  was  most  anxious  that  the  deformity  result- 
ing from  its  presence  should  be  removed.  One  small  artery  spouted 
as  the  base  of  the  growth  was  being  cut  through,  but  two  stitches 
controlled  the  ha'morrhage,  and  the  wound  healed  rapidly. 

Attached  to  the  right  side  of  the  vertex  of  the  child's  head,  about 
half  an  inch  from  the  line  of  the  sagittal  suture,  and  nearly  midway 
between  the  anterior  and  posterior  fontanclle,  was  the  tinger-like 
growth.    It  will  save  many  words  of  description  if  I  simply  state  that 


ACANTHOMA   OR   AMNIOMA  331 

it  very  closely  resembled  the  infant's  thumli,  both  in  size  and  shape. 
Of  course,  however,  it  carried  no  nail.  It  stood  out  from  the  sm-round- 
ing  hairy  scalp  on  account  of  its  being  covered  by  a  delicate  pink  and 
hairless  skin,  and  a  slight  constriction  about  its  middle  was  clearly 
visible  (Fig.  45). 

At  its  base  of  attachment  the  surrounding  skin  was  slightly 
irregular  and  thickened.  •  It  usually  lay  flat  against  the  head,  but  it 
could  be  placed  vertically,  and,  indeed,  was  freely  movable.  It  had 
evidently  no  connection  with  the  underlying  bone  or  with  a  suture. 
No  hard  rod  could  be  felt  in  it,  and  in  fact  it  had  almost  the  con- 
sistence of  a  lipoma,  which  at  first  it  was  thought  to  be.  At  the 
same  time  I  was  struck  by  the  resemblance  it  bore  to  a  preauricular 
appendage  which  I  met  with  and  removed  some  time  ago.  It  was 
therefore   with  considerable    interest  tliat   I  looked    forward   to  its 


microscopic  investigation.  It  may  be  noted  that  the  skin  of  the 
scalp  was  normal,  and  was  well  supplied  with  dark  hair. 

The  growth  was  embedded  in  paraffin,  and  horizontal  sections 
were  cut  in  the  usual  way.  The  characteristic  appearances  are 
exhibited  in  Fig.  46.  The  most  striking  feature  is  the  marked 
development  of  the  prickle-cell  layer  of  the  epidermis,  without  the 
least  indication  of  a  coincident  increase  of  the  stratum  corueum. 
There  is,  therefore,  hyperacanthosis  without  hyperkeratosis. 

Another  interesting  character  is  the  presence  of  sebaceous  glands 
in  every  stage  of  development,  from  the  simple  slight  downgrowth  of 
the  epithelium  to  the  fully  elaborated  gland,  and  .showing  all  the 
stages  between  the  undifferentiated  cell  of  the  epithelium  and  the 
highly  specialised  cell  of  the  gland.  Nevertheless  no  hairs  were  to 
be  seen  in  any  of  the  sections  examined.     There  is  no  adipose  tissue 


3;12  ANTENATAL   PATHOLOGY   AND   HYOIENE 

Id  1)C  noted,  and  the  corium  presents  no  striking  alterations ;  here 
and  there  traces  of  sudoripai-ous  glands  were  visible,  but  no  spiral 
ducts  were  observed.  At  certain  places,  and  especially  near  the 
terminations  of  the  sebaceous  glands,  open  spaces  were  noticeable, 
l)ut  I  am  inclined  to  regard  these  as  artificially  produced  during  pre- 
paration for  histological  examination.  Finally,  there  was  no  central 
rod  of  cartilage,  and  the  vascularity  of  the  tumour  was  little  marked  ; 
there  was  no  pigmentation. 

The  congenital  growth  in  this  case  consisted,  as  has  been  shown, 
of  skin;  but  it  has  to  be  noted  that  in  certain  particulars  the  skin 
was  in  an  imperfectly  developed  state.  There  were  no  hairs,  although 
the  tumour  took  its  origin  from  a  scalp  well  supplied  with  hair ;  the 
sweat  glands  were  only  represented  by  traces ;  the  sebaceous  glands 


were  present  in  every  stage  from  the  most  rudimentary  to  the  fully 
formed ;  and  there  was  a  total  absence  of  adipose  tissue  in  tlie  sub- 
cutaneous layer.  The  outstanding  feature  was  the  hyperplasia  of  the 
prickle-cell  layer.  The  first  impression  gained  from  the  study  of  the 
histology  of  the  growth  was  that  here  we  had  to  do  w'ith  tissues 
which  had  fallen  behind  in  the  general  development  of  the  body. 
The  second  notion  was  that  some  source  of  irritation  must  also  have 
been  in  action,  for,  as  Dr.  Allan  Jamieson  (wlio  was  kind  enough  to 
examine  the  sections  witli  me,  and  advise  me  thereupon)  pointeil  out, 
the  appearances,  especially  in  the  Malpighian  layer,  closely  resembled 
those  seen  in  some  forms  of  chronic  eczema.  These  ideas,  along  with 
a  similarity  in  tlie  appeai-ance  and  history  of  the  growth,  led  me  to 
e.Kamine  again  a  preauricular  ap})endage  wliich  I  removed  in  1894 
from  a  boy,  12  years  of  age.     Although  smaller  in  size,  it  resembled 


ACANTHOMA   OR   AMNIOMA  333 

in  appearance,  consistence,  and  clinical  history  the  tumour  now  under 
consideration.  In  its  histology  it  showed  a  similar  imperfectly 
developed  condition  of  the  subcutaneous  parts,  with,  however,  a  more 
mature  epidermis  and  epidermic  appendages ;  but  then,  of  course,  it 
must  be  remembered  that  it  had  been  attached  for  twelve  years  to 
the  patient's  face.  A  plate  representing  the  microscopical  appear- 
ances of  this  preauricular  growth  accompanied  the  paper  in  which  I 
recorded  its  history  and  inquired  into  its  mode  of  origin  (75). 

It  seems  to  me  that  it  is  a  probable  explanation  of  the  origin  of 
both  these  nipple-like  processes,  to  regard  them  as  due  to  delayed 
separation  of  the  amnion  from  the  body  surface,  resulting  in  a  draw- 
ing out  of  the  underlying  parts  in  the  form  of  a  small  projection. 
The  structure  of  the  projection  will  depend  upon  the  nature  of  the 
underlying  parts :  if  they  contain  cartilage,  so  proliably  will  the 
projection  ;  if  they  are  simply  made  up  of  incompletely  developed 
skin,  then  that  will  be  the  chief  constituent  of  the  projection. 

At  the  time  wiien  I  published  the  above  ca.se,  I  called  it 
interrogatively  an  acanthoma  on  account  of  the  hyperplasia  of  the 
prickle-cell  layer ;  but  that  term  scarcely  conveys  to  the  mind  the 
idea  of  immaturity  in  the  elements  of  the  skin,  which  is,  I  believe,  so 
important  a  character  of  the  appendage.  To  call  it  an  amnioma  is  of 
course  to  take  for  granted  its  amniotic  origin,  and  it  cannot  be 
definitely  proved  that  such  is  its  origin.  Nevertheless,  I  have  placed 
the  observation  here,  at  the  end  of  this  chapter  on  the  Foetal  Skin 
Diseases,  to  suggest  to  otiiers  the  need  for  tlie  investigation  of  all 
such  appendages  and  so-called  amniotic  adhesions. 

It  will  have  become  evident  to  the  reader,  if  he  has  carefully  con- 
sidered the  types  described  in  this  chapter,  that  foetal  skin  diseases  lie 
on  the  border  line  between  diseases  and  malformations.  He  will  be 
prepared  to  admit  that  .several  of  them  would  be  miich  more  correctly 
named  malformations  (even  "  monstrosities  ")  than  diseases.  From 
the  scientific  standpoint  also  many  of  them  fall  into  the  category  of 
malformations,  for  they  represent  delayed  or  disturbed  formation  of 
the  skin  or  of  parts  of  it.  This  is  one  of  the  chief  reasons  (if  it  be 
not  the  chief)  why  foetal  skin  diseases  differ  so  widely  in  their 
characters  from  postnatal  cutaneous  affections.  That  they  arise  in 
the  foetal  period  and  yet  are  malformations  is,  I  need  hardly  say,  due 
to  the  fact  that  till  ipiite  the  end  of  the  fcetal  epoch  of  antenatal  hfe 
the  skin  has  not  completed  its  development ;  it  is  still  in  the 
embryonic  or  formative  stage  when  most  of  the  other  tissues  have 
passed  out  of  that  into  the  stage  of  growth  and  active  functional  life. 
But  this  projection  of  embryonic  into  foetal  life  has  been  already 
(c.  pp.  93,  97,  98)  discussed,  and  need  not  be  further  referred  to.  I 
may  close  this  chapter  with  the  reflection,  which  is  a  most  obvious 
one,  that  in  the  future  the  dermatologist  and  the  obstetrician  must 
work  more  into  each  other's  hands,  if  progress  is  to  be  made  in  the 
study  of  the  pathology  and  pathogenesis  of  "  congenital  skins."  Let 
a  fresh  advance  be  made,  then,  and  by  the  help  of  such  an  obstetrico- 
dermatological  alliance  let  progress  be  accomplished  in  this  direction. 
Renovate  animos  ! 


CHAPTEE   XIX 

Types  of  Idiopathic  Diseases  of  tlie  Futus  (cont.)  :  Diseases  of  the  Bones  : 
Nomenclature  ;  Classification  ;  Type  A,  Characters  ;  Type  B,  Characters  ; 
Type  C,  Characters ;  Type  1),  Kxternal  Ai>pearances",  Clinical  History, 
Pathology,  Pathogenesis  ;  Type  E,  Characters  ;  Bibliography. 

Diseases  of  the  Fcetal  Skeleton. 

To  describe  with  any  pretence  to  clearness  and  exactness  the  morbid 
conditions  of  the  fcetal  bones,  is  an  impossibihty  at  the  present  time. 
The  skeleton  at  birth  is  still  partly  in  the  embryonic  or  formative 
stage,  and  diseases  and  malformations  of  its  constituent  ])arts  are 
associated  together  in  a  manner  which  proves  disconcerting  to  the 
pathologist,  and  altogether  fatal  to  the  liest  hopes  of  the  nosologist. 
Notwithstanding  tiie  accumulation  of  many  observations  of  congenital 
bone  disease,  and  notwithstanding  their  investigation  by  eminently 
competent  observers,  it  is  still  preferalile  to  avoid  any  classification 
of  them.  Possibly  it  would  be  well  to  do  here  as  I  have  done  else- 
where (8),  and  group  them  together  under  the  one  comprehensive 
title  of  "  osteogenesis  imperfecta  "  ;  at  the  same  time  it  is  only  fair  to 
indicate  some  of  the  types  which  have  been  marked  ofl'  and  described 
I)y  various  workers  in  this  most  difficult  department  of  antenatal 
pathology. 

Before  doing  so,  however,  let  me  point  out  that  the  fu_'tal  bone 
diseases  are  grouped  with  the  idiopathic  maladies  simply  for  con- 
venience, and  not  because  it  is  certain  that  they  always  arise,  as  it 
were,  spontaneously  in  the  fojtus.  They  are  not,  as  has  been  said 
already,  always  diseases,  they  are  sometimes  malformations  in  the 
correct  sense  of  the  word  :  neither  are  they  always  idiopatlnc,  they 
are  sometimes  transmitted  in  the  widest  sense  nf  the  word.  Some 
proofs  of  this  latter  statement  may  here  be  furnished.  I'orak  {De 
I'achondroplasie,  Clermont,  1890),  for  instance,  records  a  case  of  the 
disease  known  as  achondroplasia,  in  which  both  mother  and  foetus 
showed  the  same  anomaly  of  tiie  skeleton.  Further,  G.  Boeckh 
(Arch./.  Gi/nack.,  xlin.  363,  1893)  gives  in  detail  the  family  liistory 
of  an  achondroplasic  woman,  who.se  sister,  niece,  father,  and  great- 
great-grandfather  were  all  afl'ected  with  the  same  condition  of 
dwarfism.  It  has  occasionally  been  found  that  other  kinds  of 
antenatal  bone  diseases  show  this  transmission  from  ascendants  to 
descendants.  It  would  seem,  however,  to  be  a  rare  occurrence. 
Still  more  interesting  are  the  results  of  some  experiments  by  Cliarrin 
and  Gley  {Compt.  rend.  Soc.  dc  biol.,  10  s.,  ii.  705,  1895 ;  iii.  220, 1031, 


I  Ul  VERSITV  I 

FCETAL   BONE   DISEASES  335 

1896);  these  observers  succeeded,  by  inoculation  of  the  parent 
animals  with  the  toxins  of  diphtheria,  tubercle,  and  blue  pus,  in  pro- 
ducing some  young  ones  with  deformities  of  the  hind  limbs  resembling 
the  condition  known  as  "  fcetal  rickets  "  in  the  human  subject.  The 
animals  experimented  upon  were  rabbits,  and  the  males  alone  were 
inoculated  with  the  pyocyanic  toxin. 

Nomenclature. 

Many  pathologists  and  not  a  few  obstetricians  have  written  on 
the  subject  of  foetal  rickets.  As  a  general  rule,  those  who  have 
written  with  an  experience  based  upon  the  examination  or  dissection 
of  one  case  or  specimen  have  not  succeeded  in  clearing  up,  to  any 
appreciable  extent,  the  obscurity  that  surrounds  the  whole  subject ; 
their  contributions  are  often  of  great  value  as  records  of  individual 
cases,  generally  very  fully  described,  but  suggest  little  that  is  helpful 
to  an  understanding  of  the  large  problem  of  the  relation  of  antenatal 
bone  diseases  to  each  other.  Those  who,  like  E.  Kaufmann  ( Unter- 
suchungoi  ucher  die  soffcnannte  fcetalc  Rachitis,  Berlin,  1892),  have 
been  fortunate  enough  to  be  able  to  study  a  series  of  specimens,  have 
done  more  to  elucidate  the  whole  subject ;  but  even  they  have  had 
the  greatest  difficulty  with  tlie  nomenclature  of  fcetal  bone  diseases. 
Many  names  have  been  given  and  much  confusion  has  reigned,  for 
one  observer,  finding  that  his  case  did  not  exactly  resemble  one 
previously  reported  by  another  observer,  has  either  coined  a  new 
name  altogether,  or  has  added  a  qualifying  adjective  to  the  original 
designation.  A  third  observer,  finding  his  specimen  to  be  dissimilar 
to  that  of  the  second,  gave  to  it  yet  another  name ;  and  perhaps  a 
fourth  might  have  a  case  which  was  really  an  exact  reproduction  of 
the  first  of  the  series,  and  yet  he  might  coin  still  another  term  for  it, 
not  being  aware  of  the  connecting  links.  In  this  way,  or  in  some 
other  yet  more  complicated  way,  the  terminology  of  fatal  bone 
diseases  has  become  almost  hopelessly  confused,  and  out  of  this  con- 
fusion have  come  the  names,  fietal  rickets,  so-called  fcetal  rickets, 
intrauterine  rickets,  micromelic  rickets,  annular  rickets,  chondritis 
foelalis,  pseudo-chondritis,  osteogenesis  imperfecta,  achondroplasia, 
chondrodf/^troph  iafii  talis,  chondromalacic  micromcly,  congenital  cretin- 
ism, cniiiiiiid  i/i/a/j/iisiii,  ostedjHirosis,  ostcopsathj/rosis,  periosteal  aplasia 
with  osteojjsuthyivsis,  dc/celifc  endochondral  ossification,  and  rachitis 
cowjenita.  So  great  is  the  confusion  that  has  arisen,  that  I  am  not 
using  exaggerated  language  when  I  maintain  that  it  would  be  better 
if  all  the  names  were  abolished,  and  a  series  of  types,  named  A,  B, 
and  C,  instituted  in  their  place.  For  a  careful  study  of  the  literature, 
and  especially  an  inspection  of  the  accompanying  illustrations,  shows 
beyond  a  doubt  that  the  same  name  has  been  given  to  different 
pathological  and  clinical  conditions,  and  different  names  to  the  same. 
"  Foetal  rickets  "  is  a  most  glaring  example  of  this,  and  it,  at  any  rate, 
must,  I  am  convinced,  be  abandoned  henceforth  ;  "  achondroplasia  "  is 
another  instance,  although,  perhaps,  it  may  be  retained  for  its  con- 
ciseness, and  perhaps,  also,  for  its  indefiniteness  (!). 


33G  ANTENATAL    PATHOLOGY    AND   HYGIENE 

Classification. 

We  have  not  yet  reached  the  time  when  a  scientific  classitication 
of  foetal  bone  diseases  on  patliological  lines  is  possible ;  it  is  not  yet 
clear,  even,  whether  the  various  morbid  conditions  met  with  in  the 
skeleton  at  tlie  time  of  birth  are  different  diseases  or  simply  (HlVerent 
stages  in  the  same  disease.  If  any  name  whatever  is  to  l)e  given  to 
all  the  foetal  b(jne  diseases  as  a  group,  it  might  be  preferably  "  osteo- 
genesis imperfecta,"  the  denomination  introduced  hy  Yrolik  (Tabu Ice 
ad  illusirandam  Emhryoficncsin,  Tab.  xci.  Amsterdam,  1849)  in  1849, 
and  used  recently  by  H.  Stilling  (Arch.  /.  jmtk.  Anat.,  c.w.  357, 
1889),  and  others.  If  this  were  done,  then  under  this  single  name 
would  be  assembled  cases  in  which  the  defect  was  in  the  endochondral 
ossification  (J.  Symington  and  H.  A.  Thomson,  Proc.  R.  Soc.  Edinh., 
xviii.  271,  1891),  others  in  which  it  attected  the  periosteal  (S.  Mtiller, 
Milnchcn.  vied.  Abhandl.,  2  E.,  Heft  7,  1893),  and  others  in  which 
there  was  apparent  excess  in  formation  of  some  parts  of  the  skeleton 
(J.  W.  Ballautyne,  Edhih.  Med.  Jonrn.,  xxxv.  1111,  1890).  Kauf- 
mann,  in  his  large  monograph  {op.  cit.),  employed  the  general  term 
"  chondrodystrophia  foetalis,"  and  grouped  under  it  four  varieties 
of  altered  growth  of  cartilage:  (1)  a  softening  of  it,  constituting 
chondrodystrophia  malacica ;  (2)  an  arrestment  of  its  growth, 
chondrodystrophia  h3'poplastica ;  (3)  a  growth  unaccompanied  by 
increase  in  length  of  the  bones  ;  and  (4)  an  active  but  entirely 
iri'Cgular  growth  of  it,  chondrodystropliia  hyperplastiea.  I  believe  it 
will  eventually  l)e  found  to  be  possible  to  group  the  foetal  bone 
diseases  in  classes  according  to  the  period  in  antenatal  life  when  they 
were  developed ;  at  the  one  end  of  this  series  might  be  the  changes 
in  the  bones  which  occur  at  the  close  of  the  intrauterine  life,  and 
which  resemble  infantile  rickets;  at  the  other  end  would  be  the 
changes  which  are  evidently  teratological,  and  which  are  doubtless 
initiated  in  the  embryonic  epoch ;  while  in  the  middle  would  be  a 
number  of  cases  in  which  could  be  traced  some  resemblances  to 
infantile  rickets  along  with  alterations  which  could  only  be  regarded 
as  malformations  or  deformities.  In  the  meantime,  and  for  lack  of 
knowledge,  I  propose  to  describe  certain  types  under  the  headings  of 
Type  A,  Type  B,  etc. :  this  plan  may  be  unsatisfactory,  but  at  least  it 
avoids  the  coining  of  new  names,  and  the  alteration  of  the  meaning 
of  old  ones. 

FcEtal   Bone   Disease  (Type  A). 

It  will  be  convenient  to  take,  as  Type  A,  that  form  of  foetal  bone 
disease  which  there  is  some  reason  to  regard  as  rickets.  It  resembles 
as  closely  the  form  of  rickets  which  develops  in  the  second  year  of 
life,  as  any  antenatal  disease  can  resemble  any  postnatal  one;  for, 
as  has  been  pointed  out  already  several  times,  the  intrauterine 
environment  must  modify  the  manifestations  of  disease  occurring 
before  birth,  and  produce  in  it  characters  dissimilar  to  those  develoji- 
ing  after  birth.  If  I  were  to  adopt  any  special  name  for  tliis  disease, 
it  should  be  "  congenital  rickets,"  but  I  simply  denominate  it  Type  A. 


FCETAL   BONE  DISEASE  337 

Tlie  characters  are  due  to  abnormal  softness  of  the  bones,  and  are  to 
be  recognised  in  a  state  of  craniotabes  (often  very  marked),  and 
in  considerable  curving  and  shortening  of  the  long  bones.  The 
disease  cannot  be  diagnosed  by  simple  inspection  of  the  infant,  but 
requires  palpation  and  careful  mensuration.  I  believe  that  some- 
times the  only  evidence  of  the  disease  is  to  be  found  in  the  state  of 
the  cranial  bones,  although  I  admit  that  if  this  conclusion  be  accepted 
it  becomes  very  difficult  to  separate  these  cases  from  syphilis.  In 
1899,  Dr.  Jas.  11.  Watson  of  Hamilton  sent  to  me  for  examination 
a  male  infant,  six  weeks  old,  who  showed  very  marked  imperfect 
ossification  of  the  cranial  bones.  In  fact,  the  cranial  vault  felt  as  if 
composed  of  a  number  of  Wormian  bones.  The  history  of  the  case 
was  interesting.  The  motlier,  age  27,  1-para,  had  suffered  greatly 
from  vomiting  in  the  last  two  months  of  pregnancy,  and  had  been 
very  weak  at  the  time  of  her  confinement.  She  had  internal 
strabismiis  of  the  right  eye.  The  labour  was  characterised  by  almost 
complete  uterine  inertia  ;  Dr.  Watson  delivered  by  means  of  forceps  ; 
and  there  was  some  third  stage  hiemorrhage.  The  craniotabetic 
condition  of  the  infant  was  recognised  during  the  labour,  and  it  was 
quite  marked  at  the  time  of  birth  ;  it  had  not  got  any  worse,  in  fact 
there  had  been  some  hardening  up  of  the  bones  at  the  time  when  I 
saw  the  child.  There  was  no  hydrocephalic  enlargement,  and  the 
occipito-frontal  circumference  measured  151-  inches.  The  occipital 
protuberance  was  very  prominent,  and  the  palate  had  a  high  arch 
anteriorly.  The  hands  and  feet  were  well  formed.  There  was  some 
snuffling  during  suckling,  but  no  history  of  syphilis  was  elicited  (I 
interviewed  both  parents).  I  am  inclined  to  regard  this  case  as  an 
example  of  Type  A.  It  is  an  interesting  fact  that  on  account  of  the 
vomiting  the  mother  should  have  been  so  ill  nourished  at  the  close 
of  her  pregnancy.  At  the  present  time  (November  1901)  the  cranial 
bones  are  ossified,  but  the  fontanelles  still  remain  open,  but  sliow 
signs  of  closing.  The  child  has  developed  a  squint  resembling  that 
in  the  mother.     The  intelligence  is  very  good. 

If  we  regard  this  case  and  others  resembling  it  as  examples  of 
rickets  present  at  birth  and  developing  during  the  last  trimester  of 
pregnancy,  then  the  question  of  frequency  arises.  In  respect  to 
this  matter  the  greatest  divergence  of  opinion  would  appear  to  exist. 
According  to  F.  Scliwarz  {Med.  JaJirl.,  Wien,  n.  F.,  ii.  495,  1887),  of 
500  new-born  infants  at  the  Second  Vienna  Obstetric  Clinic,  80'6 
per  cent,  showed  rachitic  changes  in  the  skull  or  in  the  ribs,  or  in 
both  skull  and  ribs ;  the  mothers  had  nearly  all  been  under  bad 
hygienic  conditions  during  pregnancy.  According  to  F.  Fede  and 
E.  Cacace  {Pediatria,  viii.  41,  1900),  on  the  other  hand,  congenital 
rickets  is  comparatively  rare.  These  observers  made  a  series  of  very 
careful  measurements  of  the  length  of  the  body  and  of  the  cranial  and 
thoracic  circumferences  in  500  new-born  infants  in  Italy.  They 
employed  a  special  measuring  instrument  or  brefomacrometer ;  and 
they  made  observations,  also,  on  the  sutures  and  fontanelles.  Only 
one  case  out  of  the  five  hundred  showed  all  the  clinical  features  of 
rickets,  and  only   four  others  exhibited  craniotabes.     Even  if  the 


338 


ANTENATAL   I'ATIIOLOCIY   AND   HYCIKNK 


cases  of  craniotabes  be  admitted  as  rachitic,  it  follows  lliiit  only  in 
one  per  cent,  of  infants  born  in  maternity  practice  is  there  evidence 
of  congenital  rickets.  Irregnlaritie.s  in  the  sutures  and  foulanelles 
were  frequent ;  but  Fede  and  Cacacc  did  not  regard  these  as  signs  of 
incipient  rickets,  liut  as  evidence  of  a  retarded  development.  So  far 
as  my  own  experience  goes,  it  agi-ees  with  the  estimate  made  by 
Fede  and  Cacace  ratlier  ti)an  witli  that  furnishcil  liy  Schwarz. 


Foetal  Bone  Disease  (Type  B). 

As  an  example  of  Type  B,  I  take  the  specimen  of  bone  disease 
sent  to  me  by  Ur.  Samuel  Davidson  (Fig.  47)  in  189o.     The  foetus 


*; 


was  the  result  of  the  seventh  pregnancy  of  a  woman,  age  thirty-two, 
who  had  enjoyed  good  health,  but  who  had  been  married  when  only 
fifteen  years  old.  All  her  pregnancies  had  gone  to  the  full  term,  all 
the  infants  had  been  born  alive,  and  all  had  been  fed  at  the  breast. 
One  child  had  died  at  thirteen  months  from  "  convulsions,"  and  one 
at  one  month  from  "  bowel-hives."  During  the  pregnancy  which 
ended  in  the  birth  of  the  diseased  foetus,  the  mother  had  suilered 
more  from  vomiting  than  on  any  other  occasion,  and  had  not  felt 


FCKTAL   BOXE  DISEASE  339 

fcetal  movements  so  strongly.  There  was  hydramnios;  the  infant 
was  dead  when  born,  but  must  have  died  during  delivery,  as  foetal 
movements  were  felt  at  the  beginning  of  the  labour.  Tlie  umbilical 
cord  was  only  a  foot  in  length.  There  was  partial  placenta  pnuxia, 
which  caused  considerable  haemorrhage  during  labour,  and  was 
probably  the  cause  oi  the  infant's  death.  The  father  was  a  healthy 
man,  but  much  addicted  to  the  use  of  alcohol  in  e.xcess.  There  was 
no  family  history  of  bone  disease.  The  fcetus,  a  female,  weighed 
2160  grms.,  and  its  length  with  the  lower  limbs  in  the  position  seen 
in  Fig.  47  was  38  cms. ;  the  distance  from  finger-tip  to  finger-tip 
with  the  arms  extended  was  32  cms.  The  occipito-frontal  circum- 
ference of  the  head  was  33  cms.,  and  the  occipito-mental,  37  cms. 
It  was  evident  at  a  glance  that  the  infant  was  abnormal.  The  lower 
limbs  were  fixed  in  an  unnatural  position ;  the  thighs  were  sharply 
abducted  and  passed  outwards  almost  at  right  angles  to  the  pelvis, 
the  legs  were  partly  flexed,  and  showed  a  marked  concavity  on  the 
inner  aspect,  and  the  feet  were  turned  sharply  inwards.  Both  the 
lower  and  upper  extremities  seemed  slightly  shorter  than  is  normal, 
and  on  both  there  seemed  to  be  some  deepening  of  the  natural 
flexures.  The  head  was  broader  than  usual,  and  the  nose  short  and 
somewhat  flattened,  with  a  depressed  bridge  ;  the  eyelids  were  thick, 
and  the  cheeks  prominent ;  there  was  a  very  evident  double  chin. 
The  abdomen  was  prominent ;  and  the  whole  body  had  a  plump 
appearance,  due  to  the  presence  of  a  tliick  layer  of  subcutaneous 
tissue.  Palpation  revealed  a  soft  and  imperfectly  ossified  cranium ; 
the  limbs  could  be  moved  with  ditticulty,  and  when  this  was  done  a 
creaking  semsation  was  felt  at  all  the  joints.  During  manipulation 
the  femora  were  fractured,  indicating  the  presence  of  fragility. 

A  frozen  section  of  the  fcetus  was  made,  and  the  appearances 
found  are  represented  in  Plate  XL  The  bladder  contained  more 
than  60  c.c.  of  non-albuminous  urine,  and  the  stomach  (not  seen 
m  Plate  XL,  which  shows  only  the  right  side  of  the  body)  was 
distended  with  over  200  c.c.  of  albuminous  fluid  (liquor  amnii  ?). 
The  section  may  be  usefully  compared  with  that  shown  in  Fig.  17 
(p.  102).  The  thinness  of  the  bones  of  the  cranial  vault  is  to  be 
noted,  as  is  also  the  normal  ossification  of  the  basis  cranii.  There 
was  absolutely  no  indication  of  hydrocephalus,  a  fact  which  lateral 
sections  demonstrated  more  clearly  than  this  mesial  one.  The 
internal  organs,  including  the  thyroid  and  thymus,  had  their  normal 
appearances  and  relations.  A  plug  of  mucus  (!)  was  seen  blocking 
the  larynx  and  upper  part  of  the  trachea.  The  ossification  of  the 
stermun  was  not  far  advanced ;  and  although  there  was  the  normal 
number  of  vertebra?,  some  of  those  in  the  dorsal  region  were  evidently 
defective.  The  spinal  column  exhibited  the  usual  antero-posterior 
cm'ves  seen  at  this  age ;  but  there  were  some  lateral  bends  in  the 
dorsal  region  which  are  pathological.  The  conclusion  to  be  drawn 
from  a  study  of  the  sectional  appearances  is,  that  save  in  the  ossifi- 
cation of  the  sternum,  the  cranial  vault,  and  the  vertebrae,  there  is 
nothing  abnormal  in  the  anatomy  of  the  head  and  trunk.  The  limbs, 
however,  were  obviously  abnormal,  for  in  addition  to  their  curvature 


340  ANTENATAL   l'ATH()I.()C;Y   AM)    IIYCIKNE 

and  to  the  fragility  of  the  bones,  there  was  some  actual  shorten- 
ing, each  arm  measuring  14  cms.,  and  each  leg  1?>  cms.,  in  a  stretched 
out  position.  The  length  of  tlie  trunk  and  head  from  vertex  to 
perineum  was  SS'u  cms.  There  was  no  marked  epipiiysial  enlarge- 
ment of  the  long  bones.  The  fraetm-es  were  situated  about  the 
middle  of  the  shafts,  and  were  not  "  green-stick  "  in  ciiaracter. 

It  may  be  asked  whether  this  ca.se  and  those  that  rcsemlile  it  are 
instances  of  rickets  or  of  some  other  malady,  and  I  think  the  answer 
must  be  that  it  is  quite  ]iossil)le  that  this  malady  is  rickets.  I'erliajis, 
also,  it  may  l)e  regarded  as  rickets  beginning  at  an  earlier  dale  in 
intrauterine  life  than  in  Type  A.  If,  however,  any  separate  name 
is  to  be  given  to  it,  tlien  the  term  "osteogenesis  imperfecta"  woidd 
be  not  unsuitable.  rossil>ly  several  of  the  many  cases  collected 
together  by  J.  P.  Crozer  Griffith  (Amcr.  Jonrn.  Med.  Sc,  cxiii.  42G, 
1897),  under  the  name  idiojiathic  osteopsathyrosis,  may  have  been 
examples  of  Type  B.  Vrolik's  case  {loc.  cit.)  seems  to  have  lieen 
an  instance  of  it,  as  were  also  proljablv  those  of  G.  Barling  {Birmiiui- 
ham  Med.  En:,  xxxi.  107,  1892),  Poraki  {op.  cit.,  p.  11),  B.  0.  :\Iason 
{Arch.  Pediat.,  xi.  670,  1894),  C.  W.  Townsend  {ibid.,  xi.  761,  1894), 
and  many  others.  Connecting  links  between  instances  of  Type  A 
and  Type  B  exist ;  they  have  not  all  the  characters  of  B,  while 
they  have  more  than  the  characters  of  A.  The  reader  who  is 
specially  interested  in  fcetal  bone  diseases  may  also  study  with 
profit  H.  Stilling's  article  {Arch.  f.  path.  Anat.,  cxv.  357,  1889) 
and  H.  Hildebrandt's  {ihid.,  clviii.  426,  1899). 

Fcetal  Bone  Disease  (Type  C). 

As  an  instance  of  Type  C,  I  take  the  case  published  by  me  in  1889 
(36).  It  was  a  specimen  kindly  lent  to  me  for  examination  l)y  Sir 
William  Turner,  to  whom  it  had  been  .sent,  without  clinical  notes  or 
sender's  name,  from  the  Isle  of  Man.  Tlie  external  appearances  are 
represented  in  Figs.  48  and  49. 

These  drawings  represent  in  a  very  faithful  manner  the  pecuHar  and 
characteristic  features  which  the  specimen  showed.  The  limbs  are  curiously 
contorted,  and  nodular  swellings  mark  the  position  of  the  shoulder,  elbow, 
wrist,  hip,  knee,  and  ankle  joints.  In  the  position  of  the  coccyx  is  a  tail- 
like projection.  The  fingers  and  toes  are  long,  and  are  widely  separated 
from  each  other.  The  head  a]ipcars  to  be  large  in  comparison  with  the 
body,  the  upper  jaw  is  somewhat  prominent,  and  the  occipital  region  is 
flattened.  There  is  on  the  face  a  peculiar  senile  look,  quite  foreign  to  the 
expression  of  the  healthy  new-born  infant.  The  nndiilical  cord  is  seen  to 
be  attached  to  the  abdomen,  and  shows  no  signs  of  having  been  tieil.  The 
attitude  in  which  the  foetus  lies  is  characteristic,  and  is  most  probably 
approximately  that  which  it  occupied  in  utcro.  The  head  is  flexed  ui)on 
the  sternum,  the  arms  are  foliled  upon  tlie  chest,  and  the  legs  are  flexed 
and  curiously  interlocked.  The  thorax  is  expanded  at  its  base,  and  is 
narrow  from  side  to  side  anteriorly.  These  are  the  appearani'es  shown  in 
the   first  drawing   (Eig.   48) ;    the   second  (Fig.   49)    shows  the   peculiar 

'  Poiak's  first  case,  liore  rcfi-rrcd  to,  does  not  seem  to  liavr  lutii  an  instance  of  tim- 
achoudroplasia,  but  of  Type  B. 


FCETAL   BONE   DISEASE 


341 


deformities  of  tlie  legs  and  the  curious  appearance  of  the  external  genitals 
and  perineum.     The  swollen  knee  and  ankle  joints  are  very  evident,  as  is 


"' '  "i&^ 


also  the  projection  in  the  neighhourliood  of  the  coccyx.  A  penis  is  present, 
but  the  scrotum  is  quite  collapsed,  and  does  not  appear  as  if  it  contained 
testicles.     A  median  raphe  stretches  from  the  root  of  the  penis  to  the  anus, 


342 


ANTKXATAI.    I'ATIIOI.OCJY   AND    HYCIENK 


and  the  anal  aiicrture  is  situated  inuiiediately  in  front  of  tlie  coccygeal 
projection. 

Such  were  the  outstanding  features  wliich  tliis  specimen  presented 
to  the  eye ;  the  following  additional  characters  became  evident  on  closer 
examination.  There  was  inimohility  of  the  limbs  at  the  variou.s  joints,  and 
the  right  thigh  was  found  on  palpation  to  be  fractured.  So  firmly  fixed 
were  the  joints,  that  an  attempt  to  move,  the  arm  at  the  shouhler  resulted  in 
the  separation  (jf  the  shaft  nf  the  Immerus  from  the  head  of  the  bone.  It 
was  also  found  that  the  vertebral  column  was  rigidly  fixed  in  a  position  of 
flexion.  The  lower  end  of  the  sternum  was  tilted  sharjily  forwards,  and 
through  the  skin  the  extremely  contorted  form  of  the  scapule  could  be 
distinctly  felt.  The  total  length  of  the  foetus  was  47  cms.  (18J  inches), 
and  the  length  of  the  head  and  ti'unk  from  the  vertex  to  the  tip  of  the 
coccygeal  projectiim  was  3-5"6  cms.  (14  inches).  The  circumference  of  the 
body  at  the  level  of  the  ensiform  cartilage  was  23  cms.,  and  at  the  level  of 
the  umbilicus  21*7  cms. 

The  head  measurements  were  as  follows  : — 

Diameter  occipito-mentalis         .  .  .  =  11-.5  cms. 

Diameter  occipito-frontalis         .  .  .  =  10'2       „ 

Diameter  suboccipito-bregmatica  .  .  =  8'9      ,, 

Diameter  biparietalis         .         .  .  .  =  8-9      ,, 

Diameter  bitemporalis       .         .  .  .  =  Vw       ,, 

The  anterior  fontanelle  measured  5'1  cms.  iu  an  antero-posterior,  and 
3 '8  cms.  in  a  transverse  direction.  These  measurements  show  that  the 
head,  far  from  being  hydrocephalic,  is  rather  below  the  average  size  as 
compared  with  the  heads  of  healthy  new-born  infants  of  the  same  length  as 
this  foetus.  The  anterior  fontanelle  is,  however,  much  larger  than  is 
normal,  and  the  sutures  are  wider  than  they  are  in  healthy  infants.  The 
parietal  eminences  and  the  occipital  protuberance  were  well  marked,  and 
the  whole  head  had,  as  viewed  from  above,  a  somewhat  polygonal  outline. 

The  thorax  had  an  antero-posterior  diameter  of  5-1  cms.  superiorly,  of 
7"6  cms.  inferiorly,  and  of  6'4  cms.  at  the  level  of  the  middle  of  the 
sternum.  The  transverse  diameter  of  the  chest  at  the  level  of  the  fifth  rib 
was  5'1  cms.  The  swollen  condition  of  the  anterior  ends  of  the  ribs  could 
be  felt  through  the  skin. 

The  measurements  of  the  limbs  were  as  follows  : — 

Circumference  of  the  arm  above  the  elbow  =  6-0  cms. 

Circumference  of  the  arm  at  the  elbow       .  =  8'7  „ 

Circumference  of  the  arm  below  the  elbow  =  6'0  „ 

Circumference  of  the  leg  below  the  knee    .  =  5'1  ,, 

Circumference  of  the  leg  at  the  knee          .  =  ll'O  ,, 

The  circumference  of  the  leg  at  the  knee  was  therefore  more  than 
twice  that  below  the  knee ;  and  in  the  case  of  the  arm  the  circvnnference  at 
the  elbow  was  half  as  great  again  as  the  measurement  below  or  above  that 
joint.  These  figures  demonstrate  very  clearly  the  enormously  swnllen  con- 
dition of  the  joints  of  the  limbs. 

The  alxlomen  of  the  foetus  was  opened,  and  there  was  found  in  the 
peritoneal  cavity  a  small  (piantity  of  serous  fluitl ;  but  there  was  no  glueing 
together  of  the  intestines  or  other  sign  of  infiammation.  The  testicles, 
which  ha(i  not  descended  into  the  scrotum,  were  found  lying,  one  on  each 
side,  in  front  of  the  psoas  muscle  a  little  above  the  plane  of  the  pelvic  brim. 
The  liver,  spleen,  and  kidneys  had  a  normal  appearance,  and  the  stomach 


FCETAL   BONE   DISEASE  343 

was  empty  and  collapsed.  In  the  thorax  the  lungs  were  found  in  an 
une xpanded  condition  lying  posteriorly  to  the  heart,  and  in  the  latter  organ 
the  foramen  ovale  was  patent,  as  was  also  the  ductus  arteriosus.  It  may 
therefore  be  concluded  that  respiration  was  never  established.  Subcutan- 
eous adipose  tissue  was  found  all  over  the  body,  but  it  was  present  in 
smaller  amount  than  in  a  healthy  full-time  infant.  The  absence  of  the 
testicles  from  the  scrotum  served  to  explain  the  peculiar  appearance  of  the 
perineal  region. 

I  shall  now  describe  with  some  fulness  the  appearances  presented  by 
the  bones  in  this  foetus,  for  it  was  in  the  skeleton  that  the  most  remarkable 
characters  were  visible. 

Tlie  Cranium. — Whilst  all  the  fontanelles  of  the  head,  as  well  as  the 
coronal,  sagittal,  frontal,  and  lambdoidal  sutures,  were  wider  than  normal, 
yet  the  ossification  of  the  cranial  bones  was  irregular  rather  than  defective  ; 
and  indeed  the  bones  of  the  base  of  the  cranium  and  of  the  face  showed  a 
more  advanced  stage  of  ossification  than  they  do  in  the  healthy  infant 
at  birth.  The  parietal  bosses  were  large  and  prominent,  but  the  margins 
of  the  parietal  bones  were  thin,  flexible,  and  comb-like.  The  occipital  bone 
was  curiously  deformed.  It  had  the  shape  of  a  hook,  the  occipitals  being 
bent  at  a  sharp  angle  upon  the  supra-occiput,  and  the  basi-occiput  being 
acutely  flexed  upon  the  exoccipital  portions  of  the  bone.  The  margins  of  the 
supra-occiput  were  thin  and  flexible,  and  this  part  of  the  bone  was  flat,  a  fact 
which  explained  the  flattened  appearance  of  the  back  of  the  head  already 
described.  There  was  no  trace  of  cartilage  between  the  supra-occiput  and 
the  exoccipitals,  and  the  ossification  of  the  basi-  and  ex-occipitals  was  far 
advanced.  Whilst  the  ossification  of  the  supra-occiput  was  therefore  some- 
what defective,  the  ossific  process  was  far  advanced  in  the  basi-  and  ex- 
occipital  parts  of  the  bones, — the  parts,  it  will  be  remembered,  which 
pass  through  a  pre-cartilaginous  stage  before  becoming  bone.  The  frontal 
bone  in  the  neighbourhood  of  its  two  eminences  was  ossified,  but  the  two 
halves  of  the  bone  were  separated  by  an  inter-frontal  suture,  much  wider 
than  normal.  The  orbital  plates  of  the  frontal  bone  were  thin  and  fragile. 
All  the  parts  of  the  sphenoid  were  joined  by  osseous  union,  there  being  no 
cartilage  between  the  basi-  and  pre-sphenoid  portions  of  the  bone.  The 
rostrum  of  the  sphenoid  was  of  unusually  large  size,  being  nearly  2  cms. 
in  length,  and  was  articulated  in  the  usual  way  with  the  vomer.  The 
temporal  bones,  with  the  exception  of  the  squamous  portions,  were  well 
ossified,  and  the  tympanic  ossicles  and  annulus  tympanicus  were  as  well 
developed  as  they  are  in  the  new-born  healthy  infant.  The  ethmoid  bone 
was  normal  in  appearance.  It  was  found  that  the  two  halves  of  the  lower 
maxilla  were  well  ossified,  the  condyles  being  even  a  little  larger  than  they 
normally  are  at  birth.  The  lower  jaw  contained  the  usual  number  of 
dental  germs,  and  this  fact  is  specially  worthy  of  note,  for  it  is  well  known 
from  clinical  observation  that  when  rickets  comes  on  during  infancy  there  is 
marked  retardation  in  the  eruption  of  the  teeth,  and  great  irregularity  in 
the  mode  of  their  appearance.  The  superior  maxillae,  which  also  contained 
the  usual  dental  germs,  projected  forwards  in  the  middle  line,  and  this 
projection  I  believe  to  have  been  caused  by  the  unusually  large  size  of  the 
rostrum  of  the  sphenoid.  This  peculiarity  of  the  sphenoidal  rostrum  may 
serve  to  explain  the  beak  shape  of  the  upper  jaw  described  by  Fleischmann 
as  common  in  postnatal  rachitis.  The  malars  and  the  other  facial  bones 
were  well  developed  and  fully  ossified. 

The  Vertebral  Column  and  Pelvis. — The  spine  in  this  case  was  curved, 
and  fixedly   curved   both    laterally   and   antero-posteriorly.     There    was    a 


344        anti-:natal  pathology  and  hychenk 

convexity  to  the  left  side  in  the  cervical  ami  upper  dorsal  regions,  a  con- 
vexity to  the  right  in  the  middle  dorsal.  The  lower  dorsal  portion  of  the 
spine  was  straight,  and  there  was  a  convexity  to  the  left  in  the  lumbar 
region.  There  was  also  a  general  anterior  concavity  of  the  whole  spine. 
Such  fixed  curvatures  of  the  S|jine  are  entirely  absent  in  the  healthy  new- 
born infant.  The  sacrum  had  a  marked  promontory,  and  was  well  ossified. 
The  coccyx  was  entirely  cartilaginous,  and  was  of  enormous  size,  a  fact 
which  fully  accounted  for  the  tail-like  projection.  It  consisted  of  the  usual 
number  of  segments  (four).  The  jielvic  brim  was  contracted  in  its  antero- 
posterior diameter,  for  the  transverse  diameter  at  the  brim  exceeded  the 
antero-postcrior  by  5  mnis.  The  iliac  fossic  were  slightly  deeper  than  in  the 
normal  foetus,  and  the  crests  of  the  ilia  and  the  anterior  iliac  spines  were 
thick  and  rounded.  The  ossification  of  the  iliac  bones  was  not  so  far 
advanced  as  it  usually  is  at  birth,  whilst  that  of  the  ischial  and  pubic  bones 
was  much  retarded.  The  pelvis,  therefore,  presented  characters  quite 
different  from  those  seen  in  the  normal  foetal  pelvis,  in  which  the  antero- 
posterior diameter  at  the  brim  is  equal  to  or  greater  than  the  transverse, 
and  in  which  the  iliac  fossae  are  very  shallow.  The  pelvis,  also,  does  not 
show  all  the  characteristic  features  of  a  typical  adult  rachitic  pelvis,  although 
in  some  of  its  characters  the  resemblance  is  strong.  The  anterior  wall  of 
the  pelvis  has  an  appearance  as  if  it  had  been  compressed  and  driven  back- 
wards by  the  enormously  large  upper  extremities  of  the  femora. 

The  Clavicles  and  Scapula: — The  clavicles  were  relatively  long  when 
compared  with  the  rest  of  the  bones.  Their  inner  ends  were  enlarged,  and 
the  upper  surface  of  the  bones  showed  a  marked  concavity.  The  right 
clavicle  was  slightly  longer  than  the  left.  It  measured  3  cms. ;  the  left 
measured  2'8  cms.  The  chin  of  the  foetus  appeared  to  rest  upon  the 
upper  concave  surfaces  of  the  clavicles.  Loth  scapulae  were  remarkably 
contorted.  The  infra-  and  supra-spinous  fossae  were  very  deep,  and  the 
normal  sub-scapular  fossa  was  replaced  by  a  convexity,  upon  which,  however, 
was  a  small  concavity  corresponding  in  position  to  the  region  of  the  spine 
on  the  external  aspect  of  the  bones.  The  vertebral  border  of  each  scapula 
had  a  marked  S-sliape,  and  the  lower  angle  was  twisted  forwards.  The 
spine  of  the  scapula  had  a  distinct  projection  directed  downwards  about 
midway  between  its  two  extremities.  The  glenoid  cavity  was  not  well 
ossified. 

The  Sternum  and  the  Bibs. — The  manulirium  sterni  was  very  large,  and 
the  first  three  portions  of  the  meso-sternum  were  well  ossified.  The  eusi- 
form  cartilage  was  large,  and  its  tip  was  turned  forwards.  There  was  a 
well-marked  concavity  on  the  anterior  aspect  of  the  sternum,  with  a 
corresponding  convexity  on  its  posterior  surface.  It  may  here  be  remarked 
that  the  heart  showed  a  distinct  furrow  on  its  anterior  aspect,  marking  the 
sharp  bend  which  the  sternum  showed.  A  similar  condition  of  the  heart 
was  observed  by  Bland  Sutton  in  cases  of  rickets  in  monkeys  (Introduction 
to  General  Patholoijy,  p.  56,  London,  1886),  and  the  same  author  pointed 
out  that  marked  thinning  of  the  right  ventricular  wall  resulted  frcmi  the 
pressure  to  which  it  was  subjected  by  the  sharply-flexed  sternum.  In  this 
case  the  thinning  was  not  well  marked,  although  the  depression  upim  the 
anterior  asjjcct  of  the  heart  was  very  evident.  The  ribs,  which  were  rather 
slender  at  their  vertebral  ends,  hatl  distinct  swellings  at  their  sternal  ends. 
The  swelling  on  the  anterior  end  of  a  rib  was  hollowed  out  into  a  little 
circular  cavity  from  which  a  thin  costal  cartilage  passed  to  the  sternum.  In 
the  first  three  ribs  the  angle  was  very  sharp,  the  fourth,  fifth,  ami  sixth  ribs 
had  no  marked  angle,  whilst  the  lower  ribs  had  an  angle  not  nearly  so  well 


FGETAL   BONE   DISEASE  345 

defined  as  those  of  the  upper  three  ribs.  These  characters  of  the  ribs  were 
seen  to  correspond  to  the  convexity  and  concavity  of  the  scapula.  The 
lower  margins  of  the  middle  ribs  were  very  thin,  and  were  distinctly 
notched.  The  anterior  ends  of  the  two  upper  ribs  on  each  side  were 
directed  upwards.  In  the  case  of  the  other  ribs  they  were  directed  down- 
wanls.     The  intercostal  spaces  were  practically  non-existent. 

The  Long  Bones  of  the  Limbs. — The  long  bones  had  this  peculiarity  in 
common,  that  whilst  their  ends  were  enormously  large,  the  intervening  shaft 
was  small,  short,  straight,  and  nearly  quite  cylindrical.  In  the  case  of  the 
femur  there  was  a  trace  of  the  linea  aspera,  but  in  the  case  of  the  other 
long  bones  the  shafts  were  quite  smooth.  The  ends  of  the  long  bones  were 
composed  principally  of  cartilage  greatly  hypertrophied,  and  of  softer  con- 
sistence than  is  normal  in  the  new-born  infant ;  but  at  the  line  where  the 
cartilage  stopped  and  the  bone  began  there  was  also  a  great  thickening  of 
the  bone,  so  that  the  large  ends  of  the  bones  were  partly  osseous,  although 
principally  cartilaginous.  There  was  immobility  of  the  joints  and  a  certam 
amount  of  dislocation,  especially  in  the  case  of  the  hip,  shoulder,  and  ankle, 
and  both  the  immobility  and  dislocation  were  apparently  due  to  the 
enormous  size  of  the  opposing  cartilaginous  surfaces.  Some  of  the  char- 
acters of  the  individual  long  bones  may  be  given  here.  The  .shaft  of  the 
humerus  was  straight,  cj'lindrical,  and  short.  The  two  extremities  were 
greatly  enlarged.  The  upper  was  somewhat  round  in  form  ;  the  lower  was 
broader  transversely  than  antero-posteriorly.  There  were  no  ossific  centres 
in  the  epiphyses.  Taking  the  length  of  the  humerus  in  the  normal  infant 
as  6  cms.,  it  was  seen  that  in  this  case  the  bone  was  shorter  than  normal. 
The  left  humerus  measui'ed  4  cms.  in  length,  the  right  3'9  cms.  The 
upper  end  of  each  humerus  had  a  circumference  of  7  cms.,  whilst  the 
circumference  of  the  shaft  was  onlj'  2"1  cms.  The  radius  and  ulna  were 
of  equal  length,  each  measuring  3  "2  cms.,  but  the  radius  extended  beyond 
the  ulna  below,  and  the  ulna  passed  beyond  the  radius  at  the  elbow  joint 
above.  The  interosseous  space  was  6  mm.  in  width.  The  lower  end  of  the 
ulna  had  a  marked  concavity  inwards.  The  lower  end  of  the  radius  had  a 
circumference  of  3'-t  cms. ;  the  upper  end  had  one  of  2'6  cms.,  whilst  the 
shaft  measured  only  1'3  cms.  in  circumference.  The  upper  end  of  the  ulna 
had  a  circumference  of  3'6  cms.,  the  lower  end  one  of  3'3  cms.,  whilst  the 
shaft  had  one  of  only  I'i  cms. 

The  femur  on  both  sides  had  a  slight  concavity  in\\'ards  of  its  shaft. 
There  was  a  distinct  projection  on  the  inner  surface  of  the  upper  end 
corresponding  in  position  to  the  trochanter  minor,  but  the  trochanter  major 
was  lost  in  the  general  cartilaginous  mass.  The  head  of  the  femur  was  no 
larger  than  a  pea,  but  was  ossified.  The  femur  measured  4*5  cms.  in 
length,  the  circumference  at  the  upper  end  was  7"2  cms.,  at  the  lower  end 
8-0  cms.,  and  at  the  middle  of  the  shaft  2'1  cms.  The  tibia  was  3'3 
cms.  in  length,  and  its  shaft  had  a  circumference  of  2'1  cms.  The  shaft 
was  thicker  than  that  of  the  fibula,  which  measured  only  1  cm.  in  circum- 
ference. The  tibia  was  displaced  forwards  on  to  the  dorsum  of  the  foot. 
The  fibula  was  situated  in  a  plane  posterior  to  that  of  the  tibia,  and  more 
markedly  so  than  in  the  case  of  the  normal  infant.  It  had  a  curvature 
convex  to  the  front  and  internally,  and  concave  posteriori}'  and  externally. 
There  was  a  large  elliptical  interosseous  space  9  mms.  in  breadth.  The 
length  of  the  fibula  was  3-1  cms.,  and  it  reached  to  a  level  a  little  below 
that  of  the  tibia.     The  patella  was  large  and  cartilaginous. 

The  Hand  and  Foot. — There  was  no  point  of  ossification  in  the  carpus, 
but  the  sliafts  of  the  metacarpal  bones  were  large  and  well  ossified,  as  were 


346  ANTENATAL    PATIIOI.OCY    AND    IIVCIKNE 

also  the  first  and  second  but  not  tlie  terminal  phalanges  of  the  digits.  The 
bones  of  the  tarsus  were  cartilaginous,  except  the  os  calcis,  whieli  had  a 
large  ossific  centre.  The  feet  were  distinctly  clubbed  (talipes  varus).  All 
the  metatarsal  bones  were  ossified.  The  first  and  second  phalanges  of  all 
the  toes  were  ossified ;  the  terminal  ]>halanges  were  cartilaginous.  The 
hallu.x,  like  the  pollex,  had  both  its  phalanges  osseous. 

Such  were  the  characters  of  the  component  parts  of  the  skeleton,  and 
it  may  be  stated  in  addition,  that  at  the  time  when  the  foetus  came  into 
Sir  William  Turner's  posse.ssion  there  was  a  transverse  fracture  of  the  right 
femur  in  the  ujiper  third  of  its  shaft.  This  fracture  may  have  lieen  intra- 
uterine ;  but  I  am  more  inclined  to  believe  that  it  was  produced  at  the  time 
of  birth  or  subsequently,  for  the  long  bones  were  very  fragile,  and  during 
the  process  of  dissection  I  my.self  accidentally  fractured  the  other  femur  and 
the  right  humerus.  In  the  case  of  the  last-mentioned  bones,  however,  what 
really  occurred  wa-s  a  separation  of  the  diaphysis  from  the  epijihysis  along 
the  line  where  cartilage  and  bone  met ;  whilst  in  the  case  of  the  right  femur 
there  was  a  true  fracture  of  the  bone  itself.  Each  of  the  long  bones  pre- 
sented on  section  ver}'  similar  characters.  The  medullary  canal  was  large, 
and  was  surrounded  by  friable  spongy  osseous  tissue.  Near  the  ej)iphyses 
there  was  a  thick  layer  of  hard  bone,  and  the  epiphysial  extremities  of  the 
bone  were  composed  of  soft  cartilage  of  an  almost  gelatinous  consistence. 
The  microscopic  examination  of  the  tissues  and  organs  of  this  foetus  was 
not  satisfactory,  the  specimen  not  being  fresh  when  I  maile  the  dissection, 
but  the  swollen  ends  of  the  long  bones  and  the  whole  of  the  coccyx  seemed 
to  be  made  up  of  large  masses  of  cartilage  cells  with  little  or  no  intercellular 
matrix  and  no  deposit  of  lime  salts.  The  absence  of  the  placenta  and 
membranes  of  this  foetus  is  a  circumstance  much  to  be  regretted,  as  is  also 
the  want  of  any  clinical  history  of  the  case. 

The  remarkable  case  which  I  have  adduced  as  an  instance  of 
Type  C  resembles  in  manj'  of  its  characters  Kaufmauu's  Case  8,  but 
more  especially  his  Case  13  (oj).  cit.,  s.  130,  1892).  It  may  be  also  of 
the  same  kind  as  those  reported  by  W.  Stoeltzner  (Jahrb.f.  Kindcrhlk., 
n.  F.,  1.  106,  1899),  in  one  of  which  the  thyroid  gland  was  much 
enlarged.  If  I  were  to  adopt  Kaufmann's  nomenclature,  this  speci- 
men would  fall  under  the  heading  of  chondrodystvophia  foialh  hi/pcr- 
plastica,  for  in  it  there  is  that  extraordinarily  exuberant  overgrowth 
of  the  cartilaginous  epiphyses  of  the  long  bones  which  is  characteristic 
of  the  hyperplastic  variety  of  foetal  chondrodystrophia.  The  diaphyses 
are  very  short,  liut  the  large  size  of  the  epiphyses  almost  makes  up 
for  the  shortness  of  the  shafts,  and  so  the  limbs  are  not  so  stunted  as 
they  would  otherwise  be.  There  is  rapid  but  disorderly  proliferation 
of  cartilage,  and  the  cartilage  cells  are  not  arranged  in  rows,  and  no 
bone  formation  takes  place.  The  nose  shows  flattening,  and  at  the 
base  of  the  cranium  the  formation  of  the  os  tribasilare  takes  place 
(premature  ossification  of  the  bones  of  the  base,  namely,  pre-sphenoid, 
basi-sphenoid,  and  basi-occiput). 

At  the  present  time  the  cause  of  the  dystrophy  which  has  been 
described  above  is  unknown.  It  may  be  guessed  that  the  conditions 
which  produce  rickets  in  postnatal  life  are  active  in  a  modified  form 
or  in  a  ditfereut  degree  here,  and  tliat  they  arrest  the  formation  of  bone 
from  cartilage,  while  they  allow  the  proliferation  of  the  cartilage  itself. 


FCETAL   BONE   DISEASE 


347 


FcEtal  Bone  Disease  (Type  D). 

Under  the  heading  of  Type  D,  I  group  most  of  the  recorded  cases 
of  achondroplasia  and  chondrodystrophia  fretahs  hypoplastica.  This 
disease  does  not  prove  incompatible  with  postnatal  life ;  consequently 
there  are  several  well-recorded  instances  of  adult  achondroplasia,  as 
it  is  often  called.     I  have,  however,  to  deal  here  with  the  malady  as 


Fig.  50. — Villa's  case  of  ftetal  bone  disease. 

it  is  met  with  in  antenatal  life.  A  complete  and  concise  account  of 
the  disease,  both  as  it  occurs  in  adult  and  in  foetal  life,  is  given  by 
John  Thomson  in  Green's  jEncydojM'dia  Medica,  vol.  i.,  p.  55,  1899. 
The  external  appearances  are  very  characteristic,  and  most  of  the 
recorded  cases  bear  a  very  striking  resemblance  to  each  other.  In 
order  to  bring  out  this  resemblance,  the  reader  may  compare  together 
the  cases  of  E.  H.  Sonntag  {Dissert.,  Heidelberg,  1844),  N.  F.  Winkler 
{Arch.  f.    Gijnach,  ii.   101,  1871),  A.  Fischer  {ibid.,  vii.  45,  1875), 


348  AXTKXATAI,    I'ATIIOLOCIV   AND    HYGIENE 

J.  B.  Borntraeger  (Dissert.,  Kijnigsberg,  1877),  J.  Storp  {Dissert., 
Kiinigsberg,  1887),  A.  liiskamp  (Dissert.,  Marbiirg,  1874),  F.  Hoess 
(iJissci-t.,  :\Iaibiii'g,  1876),  1!.  Ihimpe  (Di.'iscrt.,  Marburg,  1882),  G. 
Neumann  {Diiiscrt.,  Halle,  1881),  A.  St-lmeider  (Dissert.,  Berlin,  1892), 
F.  Villa  (Ann.  cli  vstet.  e  ginec,  xiii.  Goo,  1891),  J.  Symington  and 
H.  A.  Thomson  (Proc.  Roy.  Soc,  Edin.,  xviii.  271,  1890-91), 
E.  Kaufmann  (op.  cit.),  L.  Spillmanu  (Lc  rachitisme,  I'aris,  1900),  K. 
Cestan  (Nouv.  ico7io(jr.  de  la  tialpetrih-c,  xiv.  277,  1901),  E.  Apart 
(ibid.,  p.  290,  1901),  and  F.  llegnault  (Bull,  rt  mini.  Soc.  anat.  dc  Far., 
G  s.,  iii.  178,  1901).  The  illustration  given  by  Villa  is  reproduced 
here  (Fig.  50).  The  first  glance  at  such  a  foetus  suggests  that  the 
parts  affected  are  the  exti'emities,  and  exact  measurements  at  once 
confirm  what  the  eye  has  suggested.  The  arms  and  legs  are  shorter 
than  normal ;  they  may  Ije  only  half  the  normal  length ;  and  the 
large  quantity  of  the  subcutaneous  tissue,  along  with  the  lax  condition 
of  the  skin,  gives  to  the  limbs  the  appearance  as  if  the  integument 
were  redundant,  and  so  emphasises  the  stunted  character  of  the 
appendicular  skeleton.  The  limbs  look  as  if  they  had  on  garments 
too  large  for  them,  and  they  are  often  encircled  by  deep  sulci.  The 
long  bones  belie  their  name,  for  they  are  short  and  thick,  and  have 
relatively  veiy  large  epiphyses;  but  their  epiphysial  ends  do  not 
attain  to  the  enormous  proportions  seen  in  Type  C  Their  curves  are 
exaggerations  of  those  normally  present.  The  hands  show  a  curious 
anomaly  in  form :  when,  as  J.  Thomson  first  pointed  out  (Edinh.  Med. 
Journ.,  xxviii.  1112,  1893),  the  palm  is  flat  the  fingers  do  not  lie 
parallel  as  in  a  normal  hand,  but  diverge  somewhat,  two  usually 
turning  towards  the  radial  and  two  towards  the  ulnar  side.  Good 
illustrations  of  "  le  main  en  trident "  as  it  appears  in  postnatal  life 
are  given  by  E.  Gestan  (loc.  cit.,  p.  280).  The  shortness  of  the  limbs 
is  the  character  which  has  led  several  authors  to  name  this  malady 
micromelic  rickets  or  fcetal  rickets  with  micromely. 

The  trunk,  unlike  the  limbs,  is  of  normal  length,  but  seems  to  be 
narrow  on  account  of  the  costal  and  pelvic  abnormalities.  In  size, 
the  head  also  is  normal,  or  slightly  larger  than  normal ;  and  it  is 
somewhat  prominent  in  front  and  at  the  sides.  There  is  a  sulcus  at 
the  root  of  the  short,  thick  nose ;  and  it  appears  to  be  deeper  than  it 
really  is  on  account  of  the  bulging  frontal  region.  The  tongue  not 
uncommonly  protrudes  slightly  from  the  partly  open  mouth.  The 
skin,  hair,  and  nails  are  connnonly  quite  nnrmal:  but  the  disease  may 
be  associated  with  general  fo>tal  droji.sy  (E.  Kaufmann,  op.  cit.,  s.  7). 

The  clinical  history  of  many  of  these  fa?tuses  extends  beyond 
antenatal  life,  for  although  some  succumb  a  few  hours  after  birth, 
many  survive  and  reach  the  adult  state.  In  fact,  their  development 
seems  little  interfered  with :  they  are  intelligent  and  vigorous,  and 
when  married  are  not  sterile.  As  has  already  been  pointed  out,  a 
woman  with  this  disease  may  give  birth  to  an  infant  similarly  affected 
(I'orak,  op.  cit.).  Her  labours,  hdwever,  are  apt  to  be  very  dangerous 
from  the  existing  jielvic  deformity.  In  antenatal  life,  liydraniuios, 
that  frequent  indication  of  the  presence  of  fo'tal  di.sease  and  deformity, 
may  be  present,  and  labour  often  is  somewhat  premature. 


F(ETAL   BOXE   DISP:ASE  349 

The  patliology  of  the  disease  is  now  much  better  known  than 
formerly.  The  internal  organs  show  little  or  no  pathological  change, 
and  this  remark  applies  to  the  thyroid  gland  as  well  as  to  the  other 
viscera ;  in  Symington  and  Thomson's  case,  however,  a  condition  of 
acute  desquamative  catarrh  was  discovered  in  the  thyroid.  The 
parts  at  the  base  of  the  braia  exhibit  some  anomalies,  but  these 
are  due  to  the  curious  condition  of  premature  ossification  of  the 
bones  of  the  basis  cranii,  which  results  in  their  fusion  into  one 
jjone,  the  os  tribasilare  (so  called  because  it  cijnsists  of  the  three 
nuclei — basi-occipital,  post-sphenoid,  and  pre-spheuoid).  There  is 
thus  a  marked  shortening  of  the  base  of  the  cranium  anterior  to 
the  foramen  magnum.  The  result  is  that  the  medulla  and  pons, 
which  normally  extend  from  the  foramen  magnum  to  the  upper 
edge  of  the  dorsum  of  the  sella  turcica,  project  above  that  level, 
and  have  a  direction  upwards  and  backwards  instead  of  upwards 
and  slightly  forwards.  There  are  or  may  be  other  changes  in  the 
relations  of  the  parts  of  the  brain  produced  in  the  same  way,  and 
of  the.se  Symhigton  and  Thomson  (loc.  cit.)  give  a  good  description. 
The  depression  at  the  root  of  the  nose  may  be  due  to  the  premature 
ossification  of  the  basis  cranii;  but  it  cannot  be  regarded  as  indi- 
cating with  certainty  the  presence  of  the  os  tiibasilare,  for  it  may  be 
found  when  there  is  no  tribasilar  bone  at  all  (E.  Kaufmann,  ojj.  cit., 
p.  36).  The  pituitary  body  has  been  exammed  and  found  to  be 
normal.  Hydrocephalus  has  sometimes  been  described;  but  it  is 
doulitful  if  it  is  at  all  frequent. 

The  chief  pathological  changes  are  in  the  skeleton,  and  in  that 
part  of  the  skeleton  ossified  in  cartilage.  The  bones,  therefore,  which 
are  formed  in  membrane  are  usually  quite  normal;  such  are  the 
Hat  bones  of  the  cranial  vault.  Further,  it  has  been  pointed  out 
by  Symington  and  Thomson  {loc.  cit.,  p.  273)  that  those  bones  which, 
although  formed  in  cartilage,  remain  entirely  or  mainly  cartilaginous 
till  an  advanced  period  of  foetal  life,  and  the  growth  of  which  there- 
fore is  independent  of  endochondral  ossification,  also  show  no  abnor- 
malities ;  such  are  the  sternum,  patella,  costal  cartilages,  and  tarsal 
and  carpal  bones.  In  a  sentence,  the  skeletal  changes  are  mainly 
due  to  defective  endochondral  ossification,  and  the  bones  affected 
are  consequentlj'  the  long  bones  of  the  limbs,  the  ribs,  the  innominate 
bones,  and  the  posterior  part  of  the  base  of  the  skull.  The  formation 
of  the  tribasilar  bone  has  already  been  referred  to ;  but,  in  addition 
to  that  synostosis,  the  lower  part  of  the  supra-occipital,  the  basi- 
occipital,  and  the  ex-occipitals  are  smaller  than  normal,  and  the 
supra-occipital  is  not  separated  from  the  ex-occipitals  by  a  cartil- 
aginous hinge.  The  foramen  magnum,  therefore,  is  small.  The  lateral 
masses  of  the  ethmoid  are  smaller  than  normal,  as  are  the  lesser 
wings  of  the  sphenoid,  and  the  petro-mastoid  part  of  the  temporals. 
The  inferior  maxilla  is,  as  a  rule,  the  only  facial  bone  showing  any 
abnormality ;  it  is  smaller  than  usual  on  account  of  smallness  of 
its  posterior  part.  The  vertebral  column  is  of  normal  length,  but 
its  antero-posterior  measurements  may  be  reduced :  the  thorax  is 
small  and  flattened,  a  character  due  to  arrested  development  of  the 


350  ANTl'.NATAL    I'AI'IIOLOCV    AND    ll'^dlKNE 

ribs,  wliich  may  be  less  than  one-half  their  normal  length ;  the 
pelvis  is  contracted  in  all  its  diameters,  l)ut  especiall)'  in  the  antero- 
posterior at  the  brim.  Tlie  innominate  bones  are  small,  and  almost 
entirely  composed  of  cartilage.  Tlie  diajihyses  of  the  various  long 
bones  are  from  one-half  to  one-third  their  normal  length,  but  the 
epiphyses  are  normal  in  size  or  increased.  The  shafts  have  a  normal 
circumference,  Imt  they  are  markedly  curved,  the  curves  being  an 
exaggeration  of  th(jse  normally  present ;  they  are  firm,  and  the 
so-called  fractures  are  generally  due  to  sejiaration  of  shaft  frf)m 
epiphysis  rather  than  to  a  solution  of  continuily  of  the  former. 
There  is  fixation,  or  very  limited  movement  of  the  joints  of  the 
limbs,  due  to  the  large  size  of  the  opposed  surfaces.  The  scapula 
and  clavicle  may  be  smaller  than  normal,  and  the  sternum  may 
be  entirely  cartilaginous. 

The  pathogenesis  of  this  type  of  fd'tal  bone  disease  is  hardly 
better  understood  than  tliat  of  any  of  the  other  types.  From  the 
microscopical  appearances  of  the  bones,  however,  it  is  gatliered  that 
at  the  junction  of  the  small  wedge  of  endochondral  lione  and  the 
terminal  cartilage  no  normal  ossification  is  going  on ;  "  there  are " 
(to  quote  Symington  and  Thomson)  "  no  parallel  rows  of  cells,  no 
progressive  formation  of  medullary  spaces  by  the  projection  of 
medullary  blood  vessels  into  the  cartilage ;  there  is  an  absence 
of  vessels  at  the  ossifying  junction ;  and  the  typical  organ  -  pipe 
arrangement  of  structures  is  either  not  recognisable  at  all,  or  only 
here  and  there,  and  that  faintly."  The  large  cartilaginous  ends  of 
the  long  bones  consist  entirely  of  hyaline  cai'tilage,  and  the  short 
shafts  are  made  up  almost  exclusively  of  periosteal  bone,  in 
which  a  medullary  canal  is  absent,  or  represented  only  by  some 
inter  -  trabecular  spaces,  slightly  larger  than  usual.  In  this  way 
the  growth  of  the  medullary  vessels  towards  the  ossifying  junction 
is  prevented.  Some  endochondral  bone  may  be  found  near  the  ends 
where  it  forms  the  small  wedge  referred  to  above ;  but  it  is  non- 
lamellated,  and  sim])ly  consists  of  "  a  very  irregular  honeycomb, 
made  up  of  branching  masses,  each  of  which  contains  a  core  of 
cartilage  in  the  centre ;  it  may  have  been  formed  by  a  direct  con- 
version or  metaplasia  of  the  cartilage  into  bone."  What  the  exciting 
or  predisposing  causes  of  this  arrest  of  endochondral  ossification  are, 
is  not  known.  A  great  deal  of  time  has  been  spent  over  discussions 
as  to  whether  the  disease  is  a  fcetal  form  of  rickets  or  of  cretinism  ; 
but  sucli  discussions  must  to  a  large  extent  be  wasted  labour,  for 
it  cannot  be  expected  that  the  characters  of  rickets  (u-  of  sporadic 
cretinism  as  they  occur  in  postnatal  life  will  be  exactly  reproduced 
in  fwtal  existence,  and  especially  in  the  early  part  of  fwtal  existence 
bordering  upon  the  embryonic  state.  The  cases  of  Type  D  which 
survive  birtli  certainly  do  not  grow  either  into  cretins  or  into  rachitic 
dwarfs.  That  it  may  be  duo  to  morbid  action  of  the  thyroid  gland 
is  not  b}'  any  means  ju'oven. 

That  Type  D  is  closely  related  to  Type  C  is  evident,  although 
in  the  latter  there  is  a  more  marked  overgrowth  of  tlie  epiphysial 
cartilage  which  partly  masks  the  resemblance.    E.  Kaufmann  empha- 


I 


F(ETAL   BONE   DISEASE  351 

sizes  this  resemblance  by  caUiiig  the  latter  the  hyperplastic  form 
of  foetal  chondrodystrophia,  and  the  former  the  hj'poplastic  variety  ; 
but,  to  niy  mind,  it  is  well  to  regard  them  as  two  types.  They  are 
morliid  states  which  must  arise  near  the  beginning  of  fcetal  Ufa, 
possibly  in  the  ueofcetal  period  or  even  earlier :  they  verge  upon 
the  teratological,  even  if  they  are  not  actually  to  be  regarded  as 
monstrosities  rather  than  diseases.  The  projection  of  embi-yonic 
pathology  into  foetal  pathology  in  them  is  very  evident. 

Finally,  it  may  be  noted  as  an  interesting  fact,  that  the  disease  evi- 
dently existed  and  was  noted  in  very  early  times  in  the  world's  history, 


r^ 


for  the  gods  Ptah  and  Bes  were  undoubtedly  examples  of  it.  Further, 
some  of  the  historic  dwarfs  seem  to  have  owed  their  dwarfism  to 
this  form  of  foetal  bone  disease  (Charcot  et  Eiclier,  Lcs  diformcs  dans 
I'art,  p.  15,  1899  ;  H.  Meige,  Xouv.  iconogr.  de  la  Salpvtricre,  xiv.  371, 
1901).  The  disease  is  met  with  also  in  some  of  the  lower  animals,  as 
is  seen  in  dachshunds  and  bassets. 

FcEtal  Bone  Disease  (Type  E). 

I  do  not  regard  type  E,  which  is  represented  in  Fig.  51,  as  a 
fcetal  disease  properly  so  called,  for  it  is  undoubtedly  teratological 


352  ANTENATAL   l'ATIl()L()(iV   AND    HYGIENE 

in  its  nature :  l)ut  I  describe  it  here  in  order  to  demonstrate  that 
it  is  a  still  earlier  stage  of  arrest  of  limb-formation  than  that  seen 
in  Type  D.  In  the  specimen  represented  in  Fij,'.  51,  1  found,  on 
dissection  of  the  limbs,  that  their  skeleton  was  represented  solely 
by  tiny  pieces  of  cartilage  having  a  certain  resemblance  in  shape 
to  the  bones  of  which  they  were  the  only  traces.  They  were 
eml)edded  in  a  large  quantity  of  adipose  and  coiniective  tissue, 
for  the  muscles  were  feelily  marked.  This  specimen  was  shown 
to  the  Edinburgh  Obstetrical  Society  in  1888  (Trans.  Edin.  Ohst. 
Sot'.,  xiv.  1,  1889)  by  Professor  A.  1!.  Simpson,  who  was  kind  enough 
to  allow  me  to  dissect  it.  The  skin  was  afterwards  stuil'ed,  so  as 
to  preserve  the  external  appearances,  and  it  is  now  in  the  Obstet- 
rical Museum  in  the  University  of  Edinburgh.  It  was  a  Maternity 
Hospital  case,  and  the  mother  had  already  borne  several  healthy 
children.  There  had  been  hydranniios.  The  head  had  presented, 
but  the  labour  had  been  ended  by  version.  The  two  halves  of 
the  frontal  Iwne  were  widely  separated,  and  the  \"arious  ])arts  of 
the  occipital  bone  were  prematurely  ossified  together  and  deformed, 
with  the  result  that  the  foramen  magnum  was  greatly  reduced  in 
size.  The  basi-occipital,  basi-sphenoid,  and  pre-sphenoid  were  fused 
together  into  one  bone  (os  tribasilare).  There  was  only  one  artery 
in  the  umbilical  cord. 

As  has  been  said,  this  fretus  was  evidently  teratological.  In 
teratological  classifications  it  would  doubtless  be  grouped  under 
the  heading  of  phocomelus,  although  its  characters  do  not  quite 
agree  with  those  of  that  type,  for  the  hands  and  feet  are  not 
directly  attached  to  the  trunk,  but  through  the  intermediation  of 
stunted  upper  arms  and  forearms  and  thighs  and  leg.s.  The  speci- 
men is  specially  valuable  as  showing  arrestment  of  limb  ossification 
at  an  early  period  in  antenatal  life,  at  a  time,  in  fact,  when  the 
organism  is  still  in  the  embryonic,  and  has  not  yet  readied  the 
neo-foetal  epoch.  It  is  a  monstrosity,  then ;  but  it  has  to  be 
remarked  that  it  is  connected  by  means  of  Types  D,  C,  and  B  with 
Type  A.  It  stands  at  the  one  end  of  a  series  of  types  wiiich  has 
simple  imperfect  ossification  of  the  cranial  vault  bones  at  the  other 
end.  The  ossification  of  the  limb  bones  has  been  arrested,  while 
the  ossification  of  the  Imiies  at  the  base  of  the  cranium  has  been 
prematurely  accomplished  with  resulting  deformity  in  eacli.  This 
same  coexistence  in  the  one  skeleton  of  arrested  ossification  and 
premature  cssification  is  present  also  in  Types  D  and  L\  although 
to  a  less  marked  degree.  In  Type  B,  it  would  appear  that  the 
cranial  base  is  normally  formed,  although  the  liml)  bones  and  the 
vault  bones  show  defect ;  while  in  Type  A  the  vault  bones  alone 
would  seem  to  be  affected.  At  the  one  end  of  the  series,  then, 
is  a  monstrosity,  and  at  the  other  a  disease ;  and  there  are  con- 
necting links.  Doubtless  many  of  the  dillerences  are  to  be  accounted 
for  by  the  time  in  anfenatal  life  when  the  morliid  cause  (or  causes) 
came  into  operation :  but  it  is  also  possible  that  they  are  to  be  in 
some  measure  explained  by  the  action  of  essentially  diflerent  causes. 
By  this  time  it  will  have  become  evident  to  the  reader  that  the 


F(ETAL   BONE   DISEASE  ?,53 

writer  had  good  reason  for  the  statement  which  he  made  at  the 
beginning  of  this  chapter ;  and  the  foi'mer  will  now,  perhaps,  be 
prepared  to  agree  with  the  latter  that  foetal  Ijone  diseases  are 
disconcerting  to  the  pathologist  and  discouraging  to  the  nosologist. 
One  is  tempted  to  say  about  them,  as  has  been  said  about  the 
hydatid  mole,  that  they  are  due  to  an  "  unknown  something  of  the 
mother "  (einen  unbekannten  Etwas  der  Mutter).  I  feel  that  I 
have  not  succeeded  in  introducing  into  this  chapter  any  perceptible 
degree  of  lucidity  and  order,  and  in  the  face  of  what  I  recognise 
has  been  a  failure  I  break  through  my  rule,  and  append  a  biblio- 
graphical list  of  works  on  foetal  lione  diseases,  so  that  those  readers 
who  wish  to  exphjre  this  part  of  Antenatal  Pathology  further  may 
at  least  have  the  literature  at  their  command.  May  their  success 
be  greater  than  mine. 

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Journ.  f.  Geburfsh.,  ix.  292,  1829-30;  M.\nsfeld,  Journ.  d.  C'hir.  n. 
Augenh.,  xix.  552,  1833 ;  G.  K.  A.  Schulz,  Dissert.,  Giessen,  1849 ; 
Depaul,  Bull.  Acad,  de  med.,  Paris,  xvi.  73,  1850-51 ;  J.  H.  Nutting, 
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n.  F.,  xiv.  380,  1879-80  ;  M.  Smith,  Jahrh.  f.  Kinderh.,  n.  F.,  xv.  79, 
1880;  E.  Bode,  Arch.  f.  path.  Anat.,  xciii.  421,  1883;  Gueniot,  Bidl. 
et  mem.  Hoc.  de  cMr.  de  Par.,  n.s.,  ix.  553,  948,  1883;  R.  Virchow, 
Arch.  f.  path.  Anat,  xciv.  183,  1883;  C.  Taruffi,  Mem.  r.  Accad.  d. 
sc.  d.  1st.  di  Bologna,  4.  s.,  vi.  661,  1884;  R.  von  Ferro,  Wien.  med. 
Presse,  xxvi.  374,  1885;  E.  Schidlowskt,  Dissert.,  Berlin,  1885;  V. 
Lauro,  Ann.  di  ostet.,  ix.  385,  1887  ;  J.  A.  A.  F.  Kirchberg,  Dissert., 
Marburg,  1888;  T.  Barlow,  Trans.  Clin.  Soc.  Lond.,  xxi.  290,  1888; 
A.  Kirchberg  and  F.  Marchand,  Beitr.  z.  path.  Anat.  u.  -  allg.  Path., 
V.  183,  1889  ;  0.  Blau,  Dissert.,  Berlin,  1889  ;  E.  Mori,  Rir.  di  ostet. 
e  ginec,  ii.  513,  1891  ;  L.  Scholz,  Dissert.,  Gottingen,  1892  ;  G.  Schwarz- 
waller,  Ztschr.  f.  Gehurtsh.  u.  Giindk.,  xxiv.  90,  1892;  A.  Carton, 
Tlihse,  Paris,  1893 ;  H.  Paal,  Dissert,  Wiirzburg,  1893  ;  0.  von  Franqu^, 
Sitzungsh.  d.  phys.-med.  Gesellsch.  zu  Wilrzhurg,  80,  93,  1893;  J.  Thomson, 

'  In  tliis  bibliogi-aphical  list,  the  works  already  referred  to  in  the  tfxt  are  not 
inehided. 

23 


354  ANI'KNATAl.    I'ATl  lOI.OCV    AND    llYCilKNE 

Trails.  Eiliiih.  Oh^t.  So,:,  xviii.  195,  ISO;!;  .1.  H.  R(rni,  Dhsert.,  liamlierg, 
1894  ;  roKAK  ET  DuuANTE,  Noiiv.  cirili.  il'olis/.  ft  de  ijunrr.,  ix.  298,  1894  ; 
C.  Salvetti,  Uritr.  .:.  path.  Anat.  u.  r..  all;/.  Path.,  xvi.  29,  1894;  J!.  C. 
HiHST,  Mrd.  Xeiix,  Ixiv.  184,  1894;  V.  I'ki.lo,  Arch.  lU  Ortoped,  xi.  1, 
1894;  M.  Sai,a(!Iii,  j'AiV/.,  xi.  383,  1894;  F.  Ckuttiiofk,  Dissert.,  lierlin, 
1895;  K  Apeiit,  Hull.  Soc.  anat.  ,le  Paris,  5  s.,  ix.  772,  1895;  K.  Lampe, 
Dissert.,  Mailmij,',  1S95  ;  C.  .1.  de  iiiiuvN  Koi'S,  Nederh  Tijdschr.  v. 
Geneesh.,  2.  11.,  xxxi.  350,  1895;  ('..  II.  Maki.vs,  St.  Thomas'  IIoxp.  Rep., 
U.S.,  xxiii.  121,  1896;  O.  Maugarucci,  Arch,  cd  atti  d.  Hoc.  Hal.  di  chir., 
x.  365,  1896;  CiiAMUKELENT,  Joum.  de  mi'd.  de  liordeaiix,  xxvi.  204, 
1896;  PiruEs,  ihid.,  xxvi.  479,  1896;  I'inkuss,  Ztsrh.  f.  Gehurtsh.  u. 
Gyniih:,  xxxvii.  159,  1897 ;  T.  Tsciiistowitsch,  Arch.  f.  path.  Anat., 
(!xlviii.  140,  209,  1897;  A.  Johannessen,  Xorsk  Maij.  f.  hi'ijeridenslc, 
Xo.  2,  1898;  A.  IIkuugott,  Rev.  mi'd.  de  Vest,  xxxi.  762,"l899;  C.  V..  .S. 
Flemmino,  Bristol.  Med.-C'hir.  Joum.,  xvii.  21,  1899  ;  Opitz,  Ztschr.  f. 
Gehurtsh.  it.  Gi/ndh:,  xl.  316,  1899;  B.  Schwendener,  Dissert.,  liasel, 
1899;  G.  Klem,  Xorsk  Mac/.  /.  Livrievidpn.-ik.,  4  R.,  xiv.  1,  1899;  F. 
Schmev,  Kiiider-Ar:f,  xi.  53,  1900;  Schkib,  Peitr.  z.  /din.  Chir.,  xxvi.  93, 
1900  ;  F.  Harbitz,  Beifr.  ::.  jinfh.  Anat.  n.  alhj.  Path.,  xxx.  605,  1901,  and 
Xorsk  Ma,/,  f.  Ut-gevidmsk.,  4  R.,  xvii.  1,  1901'. 


I 


OCT„g 

OF  • 


Right  lung. 


Rigitt 
ifirarenai 
cnpsuk. 


Spitui  bifida. 


CHAPTER    XX 

Types  of  Idiopathic  Diseases  of  the  Fcetus  (cont.):  Diseases  of  the  Ali- 
nieutaiy  System :  Fu'tal  Ascites,  Definition,  Clinical  Features  and  History, 
External  Apjiearances,  Morbid  Anatomy,  Etiology,  Pathology,  Treat- 
ment ;  F(etiil  Peritonitis  ;  Congenital  Obliteration  of  the  Bile-Ducts, 
Definition,  Clinical  History,  Symptomatology,  Morbid  Anatomy,  Path- 
ology, Diagnosis,  Treatment ;  Congenital  Hypertrophic  Stenosis  of  the 
Pylorus,  Definition,  Symptomatolog}-,  Morbid  Anatomy,  Pathogenesis, 
Treatment. 

Less  is  known  i-eganling  the  diseases  which  aflect  the  internal  organs 
of  the  foetus  than  about  those  involving  the  skin  or  those  of  the 
skeleton ;  for  the  examination  and  dissection  of  infants  that  have 
died  during  or  just  before  birth  has  not  been  common,  and  the  atten- 
tion of  observers  has  been  seized  only  by  the  more  obvious  external 
morbid  states.  As  a  consequence,  almost  the  only  antenatal  maladies 
of  the  alimentary  system  about  which  anything  is  known  are  those 
wliich  are  so  marked  and  so  far  advanced  as  to  produce  evident 
changes  in  the  external  configuration  of  the  body,  and  so  to  interfere 
with  the  normal  progress  of  parturition,  rromineut  among  these  is 
fatal  ascites. 

Foetal  Ascites. 

I  have  examined  by  the  sectional  method  three  specimens  of 
foetal  ascites  (58,  197,  221),  and  the  appearances  presented  by  a 
lateral  vertical  section  of  one  of  these  are  shown  in  Plate  XII.  I 
ha\'e  also  had  an  opportunity  of  examining  the  case  recorded  by  W. 
Fordyce,  and  fully  descrilaed  l^y  him  in  my  journal  {Teratologia,  i.  61, 
143,  1894).  The  following  account  of  the  malady  is  founded  upon 
these  four  specimens,  and  upon  a  consideration  of  similar  cases  which 
have  been  reported  liy  other  observers.  A  good  biljliography  accom- 
panies Fordyce's  article  {he.  cit.,  p.  135),  and  on  that  account  the  text 
here  will  not  be  bm-dened  with  many  references. 

FcEtal  ascites  may  be  defined  as  the  efi'usion  of  fluid  into  the  peri- 
toneal cavity,  with  consequent  abdominal  distension  due  to  several 
different  causes,  accompanied  by  various  lesions  of  the  \'iscera,  and 
leading  usually  to  delay  in  labour  and  to  intranatal  or  early  post- 
natal death  of  the  infant  affected  with  it.  It  is,  just  as  in  the  adult, 
a  symptom  or  effect  of  different  morbid  processes  rather  than  a 
disease  jxr  sc ;  but  the  morbid  processes  which  produce  the  antenatal 
form  are  almost  certainly  different  from  those  which  lead  to  the  adult 
variety.  Further,  antenatal  ascites  reaches  a  far  more  deforming 
degree  than  the  disease  ever  does  when  developed  in  postnatal  life. 

F.    IMauriceaii    {Traiti  d.   mcd.   d.  femmcs  grosses,  3  ed.,    Paris, 


350  y\NTKXATAI.    I'All  lOI.Od^'    AM)    HYdlKNK 

1G81)  was  OIK'  of  the  iirsl.  to  put  on  record  a  case  of  foBtal  ascites, 
and  he  gives  such  a  graphic  account  of  tlie  interference  with  the 
normal  ])rogress  of  labour  caused  by  this  antenatal  malady,  that  For- 
dyce  in  his  monograph  (loc.  cit.)  translated  the  passage  into  English. 
I  repid(hic(!  l''(irdyce's  tran-slation  here,  for  it  is  well  worth  reading. 
Mauriceau  writes : 

"  In  the  year  IGGO,  when  I  was  engaged  practising  midwifery 
in  this  place,  it  happened  one  day  that  a  nurse,  who  was  in  attend- 
ance on  a  woman  in  her  confinement,  was  unable  to  deliver  more 
than  the  head  of  the  child.  Finding  that  it  was  inipossilile  for  her 
to  extract  the  rest  of  tlie  body,  altiiougli  she  had  exhausted  herself 
in  making  strong  traction  i>n  the  liead,  she  called  in  t<i  licr  assistance 
an  experienced  midwife,  who  in  turn  did  all  in  lier  jxiwcr  to  extract 
tlie  child  by]mlling  on  its  head,  but  with  no  result  beyond  dislociiting 
the  cervical  ^■ertebra^  I  was  then  summoned  to  their  assistance. 
On  my  arrival,  they  at  once  requested  me  to  examine  the  patient  in 
order  to  discover  the  cause  which  had  prevented  them  delivering  the 
child,  although  they  had  pulled  so  strongly  on  its  head  and  had 
made  eflbrts  which  were  more  than  sufticient  to  have  delivered  tlie 
shoulders,  though  these  had  l>een  very  large.  I  very  soon  concluded 
that  the  difficulty  proceeded  from  some  other  cause  than  the  shoulders 
of  the  child,  for,  when  I  had  passed  my  tiattened  hand  up  to  the 
entrance  to  the  womb,  as  far  as  the  shoulders  of  the  cliild,  I  found  they 
did  not  appear  to  be  so  large  but  what  they  could  ha\c  ])een  easily 
delivered.  I  introduced  my  hand  further,  carrying  it  in  front  of  the 
chest  of  the  child  as  far  as  the  xyphoid  cartilage,  where  I  recognised 
that  the  abdomen  was  dropsical  and  full  of  Huid,  so  that  it  was  im- 
possible to  extract  it  withotit  liaving  first  punctured  it  in  order  to 
give  a  means  of  escape  to  the  fluid  which  it  contained.  1  had  not, 
however,  with  me  at  the  time  a  suitable  instrument  with  which  to  do 
this,  and  was  therefore  oliliged  to  send  for  a  doctor  from  the  Hotel - 
Dieu.  When  this  doctor  arrived,  I  stated  the  case  to  him,  and  de- 
clared that,  in  order  to  deliver  the  child,  it  was  neces.sary  to  puncture 
its  abdomen,  wliich  was  distended  by  llnid.  He  was,  however,  un- 
willing to  agree  with  me,  either  because  he  thought  perliaps  he  i<new 
his  work  without  my  advice,  or  because  he  did  not  wisli  to  or  could 
not  believe  that  the  child  was  dro])sical  as  I  had  told  liim.  What- 
ever was  the  cause,  he  contented  himself — without  putting  himself  to 
the  trouble  of  examining  the  case — with  attempting  delivery  in  his 
own  way.  He  made  traction  once  more  on  the  head  of  the  child, 
and  separated  it  entirelj^  from  the  rest  of  tlie  body;  for  it  was  but 
slightly  attaclied,  owing  to  the  excessive  violence  of  the  ellbrts  of  tlie 
midwives  who  liad  been  first  in  attendance  on  the  case.  After  that 
lie  introduced  a  blunt  hook  into  the  uterus  and  draggeil  away  boll i 
the  arms  of  the  fcctus,  the  one  after  the  other,  and  tlieu  some  ribs, 
and  then  parts  of  the  lungs  and  the  lieart.  F(ir  three-([uarters  f)f  an 
hour  he  employed  himself  in  thus  dragging  away  fragments  of  the 
f(etus  (during  which  time  he  ])erspired  friiely,  although  the  weatlier  at 
the  time  was  \ery  cold),  until  at  last,  dislieartened  and  exhausted,  he 
was  comiiellcd  to  abandon  the  task  and  take  a  rest.     The  midwife, 


Fa':TAL   ASCITES  357 

ineauwhilc,  succeeded  in  tearing  away  some  pieces  of  ribs,  usiny;  her 
hands  unly,  for  of  course  she  could  not  have  been  allowed  to  use  the 
blunt  hook.  A  second  time  the  doctor  tried  to  extract  the  fcetus,  pull- 
ing on  the  hook  with  all  his  strength,  but  without  any  success,  because 
up  to  this  time  he  had  not  punctured  the  abdominal  wall  or  the 
diaphragm,  not  wishing  to  do  it,  as  I  kept  telling  him  each  moment 
that  without  this  it  was  impossible  to  deliver  the  rest  of  the  body. 

"  On  seeing  that  all  his  efforts  were,  for  a  second  time,  useless,  he 
at  last  gave  me  the  blunt  hook,  saying  that  I  might  have  an  oppor- 
tunity of  tiring  myself  out  as  well  as  the  others.  I  accepted  it 
willingly  and  with  pleasure,  for  I  was  very  certain  I  could  soon  com- 
plete the  operation,  knowing  very  well  that,  instead  of  amusing 
myself  as  he  had  done,  it  was  only  necessary  to  puncture  the  abdo- 
men of  the  child  in  order  to  let  the  contained  Huid  escape,  after 
which  delivery  of  the  child  would  be  easy.  For  this  object  I  intro- 
duced my  left  hand  right  up  to  the  distended  aljdomen,  and,  passing 
the  blunt  hook  along  it,  I  turned  the  point  of  the  instrument  towards 
the  alxlominal  wall  and  forced  the  point  into  the  abdominal  cavity 
of  the  fcetus.  Then  I  withdrew  my  hand,  and  at  once  all  the  fluid 
gushed  out  in  a  torrent.  After  this  I  drew  out  the  rest  of  the  body 
with  one  hand  without  any  difficulty,  to  the  great  astonishment  of 
the  doctor,  who  had  never  been  able  to  persuade  himself  that  the 
child  was  dropsical.  After  delivery,  I  had  the  curiosity  to  till  the 
abdomen  of  the  foetus  with  water,  in  order  to  see  what  quantity  it 
had  contained,  and  what  its  size  was  when  quite  full.  I  was  able  to 
introduce,  without  exaggeration,  more  than  live  pints  of  our  Paris 
measure.  This  I  should  have  had  difficulty  in  believing  had  I  not 
seen  it.  I  record  here  the  full  history  of  the  case,  in  order  that  the 
accoucheur  may  know  how  to  act  on  a  similar  occasion." 

Mauriceau's  case  illustrates  very  well  the  difficulty  introduced 
into  parturition  when  the  fcetus  suffers  from  ascitic  distension  of  the 
abdomen :  nothing  need  be  added  to  tliis  part  of  the  clinical  history 
of  such  cases. 

The  pregnancy  whicli  ended  in  the  birth  of  an  ascitic  fcetus  was 
seldom  cpute  normal  iu  its  symptomatology.  According  to  Fijrdyce's 
statistics  of  sixty-three  cases  (loc.  cit.),  there  were  eight  instances  of 
syphilis  and  nineteen  of  hydramuios.  In  two  of  the  three  cases 
seen  by  me  there  was  bad  health  of  the  mother ;  in  one  (58)  there 
was  gonorrhcea,  with  rupture  of  a  pyosalpinx  during  labour,  and 
death  in  the  puerperium;  and  in  another  (197)  there  was  a  tubercular 
history.  In  the  third  case  (221)  the  mother  had  been  subject  to  the 
infection  of  measles,  but  had  not  apparently  been  affected  ;  Ijut  there 
was  great  hydramuios.  Not  infrequently  there  was  a  history  of  pain 
in  the  abdomen.  In  thirty-six  out  of  forty-three  cases  the  pregnancy 
termuiated  prematurely.  Sometimes  the  fcetal  malady  showed  family 
prevalence,  as  iu  the  cases  reported  by  E.  Virchow  (Monatschr.  f. 
Geburtsh.,  xi.  161,  1858),  by  0.  von  Franqucj  {Wien.  vied.  Presse,  vii. 
812,  1866),  by  Bruce  {Edin.  Med.  Journ.,  xvi.  167,  1870),  and  by 
JQden  {Dissert.,  Wurzburg,  1890). 

To  such  a  serious  extent  did   the   foetal  disease  interfere  with 


358  ANTKNAI'AI,    I'A  TIIOl-OC^    AM)    I  H  CI  I'.N  I', 

delivery,  tluil  in  four  fuses  (lut  of  sixLy-tliree  tlie  iuhUuts  dicil  as 
tlie  result  of  tile  ]ir(iloiiged  laliour  ami  tlie  operative  iuterfereuee 
(Fordyce).  The  fo'tus  usually  died  eiliier  duriui;'  or  very  so(ju  after 
its  hirtli;  but  in  Crainlall's  ease  it  lived  for  nearly  a  uioutli,  and  in 
Courniont's  it  reeovered  after  the  ahdonieu  had  been  jiunctured  and 
500  grnis.  of  fluid  withdrawn  (Fordyee).  The  prognosis  for  the 
infant,  therefore,  is  not  absolutely  hopeless. 

The  adcrnal  apjicaranccs  oi  the  ascitie  fo'tusare  strikiug(Fig.  52): 
tluu'eis  marked  jirouiineueeof  the  abdomen,  so  great  in  some  instances 
as  to  cause  a]i}iareut  dwarfing  of  the  head  and  linilis.  On  ])alpation 
the  fluctuation  thrill  can  lie  easily  elicited;  and  it  is  evident  that  the 
f'd'tal  abdomen  contains  fiuid.  Very  sindlar  results  on  inspection  and 
palpation  are  obtained  in  cases  where  the  ftetal  bladder  is  greatly 
over-distended,  so  that  it  is  not  always  certain  at  first  what  the  cause 
of  the  abdominal  enlargement  may  be  in  any  given  case.  The  limbs 
and  face  are  usually  iiuite  free  from  (edema.  Sometimes  the  e.xternal 
genitals  are  malformed,  as  in  Fordyce's  case  (I'ig.  54).  There  was 
hare-lip  in  one  of  my  cases  (221). 

The  viorbid  anatumy  has  not  been  investigated  so  fully  as  could 
be  wished,  and  in  many  of  the  recorded  cases  the  obstetric  interest 
seems  to  have  been  the  only  one  which  appealed  to  the  observer. 
The  fiuid  in  the  abdominal  cavity  has  varied  in  amount  from  a  few 
grammes  up  to  twelve  or  fifteen  litres  (!) ;  juobably  two  to  four  litres 
has  been  the  average  quantity.  It  was  generally  a  clear  serous  fiuid, 
but  sometimes  it  was  described  as  brownish  red  or  turbid,  with  fiakes 
of  lymjih  floating  in  it.  In  a  few  cases  it  was  analysed :  in  Truz/i's 
{Gaz.  incd.  ital.  lomb.,  8  s.,  vi.  139,  1884)  it  was  rich  in  albumin, 
alkaline  in  reaction,  and  had  a  sjiecific  gravity  of  1002;  in  C.  Jany's 
{Klin.  Bcitr.  z.  Gynaclc,  ii.  240,  1864)  it  was  alkaline,  and  contained 
chlorides  but  no  urea;  and  in  one  of  my  cases  (197)  it  had  a  specific 
gravity  of  1007,  an  alkaline  reaction,  and  it  contained  albmnin  and 
globulin,  and  a  distinct  trace  of  oxyha^moglobiu. 

In  about  half  the  recorded  cases  in  which  a  post-morUm  examina- 
tion was  made,  the  peritoneum  was  diseased  ;  it  showed  the  signs  of 
infiammation,  sometimes  acute,  but  generally  chronic,  which  caused 
a  thickened  or  granular  state  of  the  membrane,  with  adhesions 
between  the  various  viscera,  retraction  and  thickeuhig  of  the  mesen- 
tery, etc.  The  microscopic  aj)pearances  of  the  abdominal  wall  in 
F^ordyce's  case  are  shown  in  Fig.  58 ;  the  endothelium  was  entirely 
destroyed,  and  the  sub-endothelial  connective  tissue  greatly  thickened. 
Enormous  hypertrophy  of  the  pancreas  was  referred  to  in  one  case 
(E.  i\Iartin's  s]iecimen,  Monalschr. /.  Grhnrtsk.,  xxvii.  28,  18G5).  It  is 
a  remarkal)le  fact  that  lesions  of  the  liver  and  spleen  seem  to  have 
been  rarely  noted,  a  striking  occurrence  w'hen  the  pathology  of  ascites 
in  the  adult  is  borne  in  nund.  The  bladder  is  sometimes  found  in 
an  over-distended  condition;  and  I  have  elsewhere  (58)  gathered 
together  records  of  seventeen  cases  in  which  this  association  of  fo'tal 
ascites  and  distension  of  the  bladder  was  observed.  In  some  cases 
there  was  also  dilatation  of  the  ureters  and  hydronephrosis.  Some- 
times there  was  a  urethral  septum  or  valve  to  account  for  the  vesical 


Fig.  52.-^E.xtenial  appuaniiLrs  of  lH,tu,s  with  asritrs.     I'l.ntograi.li  from  watcT-oolour 
sketch  made  shortly  after  delivery  (reduued  Ijy  about  oue-lialf). 


360 


ANl'IAAlAl.    I'Al'llOI.OC^'    AND    I1V(;II:M 


distension,  but  sometimes  there  wiis  no  sucli  striiflini'.  In  Fonlyce's 
case  {loc.  cit.)  and  in  some  others  tiie  <;enilal  orj^ans  were  malformed, 
as  were  also  till'  lower  ])art  of  the  lari^e  intestine  and  the  rectum; 
in  the  former  there  was  a  double  uterus  and  vagina,  and  a  tubercle 
which  pi'obably  represented  the  clitoris  (Kig.  54),  and  in  OLshausen's 
specimen  {Arch./.  Gt/naclc,  ii.  280,  1871)  the  bladder  communicated 
with  the  uterus,  and  the  clitoris  was  absent. 

I  have  grouped  this  foetal  morbid  state  among  the  idinpatbic 
diseases,  and,  therefore,  it  may  be  gathered  that  I  regard  its  (iivhijji 
as  unknown.  At  the  same  time,  there  are  some  cases  in  which  it 
seems  fair  to  regard  the  ascitic  condition  as  the  result  of  foetal 
syphilis  arising  from  maternal  (or  paternal)  infection,  and  con- 
sequently as  a  transmitted  disease,  or  as  one  of  the  manifestations  of 


Fig.  53.— Mii-nwoi.i.'  ai.|.i'ar.iii(i's  nf  scrtimi  of  Al.dniuiiial  Wall 
iutciual  to  tlie  JIusciilar  Layer,  .stained  with  logwood  and 
eosin,  x  97.  a,  Muscular  tissue  ;  b,  Areolar  tissue  ;  c,  Cou- 
iiectivc  ti.ssue. 


a  transmitted  disease.  If,  liowever,  the  syphilitic  cases  be  cxcludcil, 
and  they  arc  not  numerous,  there  remain  many  in  whicli  tlie  ascites 
must  still  be  regarded  as  originating  in  the  fa>tus  ai)art  from  maternal 
states.  These  may  yet  be  traced  to  diseased  states  of  the  niotlier, 
but  this  stage  in  our  knowledge  has  not  yet  been  attained. 

In  considering  tlie  pafholo;/y  and  patho(/cnfsis  of  the  malady,  one 
naturally  thinks  first  of  hejmtic  lesions  and  disturbance  of  the  jiortal 
system  ;  but  it  has  already  been  stated  that  morbid  alterations  of  the 
liver  in  such  cases  have  been  very  rarely  nciticed.  It  woidd  seem 
that  ascites  due  to  causes  in  the  jiortal  system  is  not,  tlicrefore, 
common  in  the  fo'tus,  a  state  of  matters  not  so  difficult  to  understand, 
if  it  lie  remendiercd  tiiat  this  part  of  the  vascular  system  is  then 
comparatively  inactive  on  account  of  the  quiescent  condition  of  the 


FCETAL   ASC'ITK.S 


561 


gastro-iiitestinal  caual.  In  Herman's  case,  however,  the  cause  seems 
to  have  l)een  pressure  on  the  portal  vein  by  a  large  tumour  of  the 
right  supra-renal  capsule  {Med.  Times  and  Gax.,  ii.  731,  1881).  I5ut, 
with  few  exceptions,  the  ascites  seems  to  have  been  due  to  peritonitis, 


a  conclusion  whicli  appears  t(i  be  warninted  by  the  luorbiil  anatumy 
of  most  of  tlie  specimens.  What  the  cause  of  the  peritonitis  may 
have  been  is  not  well  known,  but  in  one  case  (Olshausen's,  loc.  cit.)  it 
was  the  escape  of  urine  into  the  peritoneal  cavity.  In  Fordyce's 
specimen  {loc.  cit.)  the  peritoneum  had  lost  its  normal  endothelial 
covering,  and  great  thickening  of  the  subendothelial  connective  tissue 


362  ANTKNATAI.    I'Al'1 1()1,(  K.V    AM)    lIVdIKNK 

had  taken  jilacc,  witli  degeneration  of  some  of  its  siiiierficial  layers 
(Fig.  5;'.).  Hardiiuin  and  Morcaii  {J<<r.  ohslrt.  interna/.,  sup}i/.,  i.  184, 
1895)  report  a  case  in  which  tlie  fo'lus  exhibited  ascites,  hydro- 
thorax,  sliglit  hydropericariHuni,  ahmg  with  cleft  i>alate  and  cardiac 
malformations ;  the  authors  regarded  the  ascites  as  due,  in  this  case, 
to  the  anomaly  of  the  heart  (absence  of  com])lete  interventricular 
septum).  It  is  necessary,  then,  to  keep  in  mind  that  f(ctal  ascites, 
like  general  fa^tal  dro]isy,  may  he  due  to  several  causal  factors;  at 
the  same  time  I'orak  and  Sevestre  (flull.  Sue.  a  mi/,  dr  Par.,  4  s.,  i. 
314,  1876)  and  Fordyce  give  the  lirsl  ]ilacc  in  the  pathogenesis  to 
peritonitis. 

There  seems  to  be  no  reason  why  aspiration  of  the  abdomen 
should  not  in  some  of  these  cases  give  relief;  if  this  i)rocedure  were 
carried  out  during  labour  as  soon  as  the  cause  of  the  delay  was  ascer- 
tained, not  only  would  the  confinement  be  quickly  ended,  but  the 
infant  might  he  born  alive  and  sur\ive  (as  one  case  at  least  has 
already  demonstrated). 

FcEtal   Peritonitis. 

As  has  been  shown  in  the  preceding  paragraphs,  jieritonitis  is  one 
of  the  pathological  causes  of  foptal  ascites,  but  I  set  apart  here  a  few 
lines  to  the  consideration  of  fcetal  jteritonitis  itself,  both  with  and 
without  effusion  of  fluid  into  the  peritoneum.  On  this  subject  J.  Y. 
Simpson  long  ago  wrote  fully  and  most  suggestively  {Ohdc/ric  Worls, 
ii.  152-205, 1856  ;  Udinb.  Med.  Sun/.  Journ.,  i.  390,  i838).  That  ante- 
natal peritonitis  may  occur  without  ascites  is  proved  liy  an  oliservation 
(131)  which  I  made  some  years  ago.  It  was  that  of  a  female  infant 
looru  in  the  Maternity  Hospital, Edinlnirgh,  after  a  somewhat  j)rolonged 
and  instrumental  labour  ;  the  infant  died  thirty-two  hours  after  birth, 
with  a  considerably  distended  abdomen.  I  found  that  the  large  and 
small  intestines  were  distended  with  gas,  and  that  the  coils  were 
glued  to  each  other,  to  the  under  surface  of  the  liver,  and  to  the  ]ielvic 
viscera.  On  separating  the  opposed  surfaces,  it  was  seen  that  the 
peritoneal  aspect  of  the  l)owel  had  a  markedly  granular  api)earance  : 
but  there  was  no  fluid  in  either  the  abdominal  or  pelvic  jieritoneal 
sacs.  There  was,  therefore,  a  recent  dry  peritonitis,  which  might,  it 
is  conceivable,  have  arisen  during  the  short  postnatal  life  of  the 
infant;  but  in  the  pelvis  were  signs  of  an  older  peritonitis,  which 
had  produced  adhesions  between  the  Fallopian  tube  and  broad  liga- 
ment and  the  ca-cum. 

It  is  easily  understood  that  comparatively  few  cases  of  foetal 
peritonitis  witiiout  effusion  have  been  recorded,  for  the  condition  does 
not  lead  to  abdominal  distension,  and  to  consequent  delay  in  labour, 
and  so  attention  is  not  focussed  ujjou  the  infant.  Even  among  the 
cases  which  are  described  as  prriionitis,  and  not  as  a.scites,  it  is  usually 
found,  as  in  the  observation  of  G.  Palazzi  {Ann.  di  odd.  c  i/i)ici\. 
xviii.  139,  1896),  that  there  has  been  Huid  in  the  peritoneal  cavity. 
Doubtless  the  dry  form  is  often  overlooked;  .sometimes  also  it  may 
not  cause  earlv  death,  but  be  to  a  large  extent  recovered  from,  and 


F(]',TAL   ASCITES  363 

only  be  detected  later  liy  the  ctlects  to  which  it  has  yiveu  lise.  It 
has  been  a  cuiiiiuoii  practice  to  ascrilie  most  of  the  iiialfonnations  of 
the  abdominal  and  pelvic  organs  to  t'letal  peritonitis  and  to  the 
adhesions  resulting  from  it ;  no  doubt  there  is  a  measure  of  truth  in 
this  theory  of  causation,  but  it  is  only  under  certain  circumstances 
that  it  can  be  accepted.  If  the  peritonitic  adhesions  form  before  the 
malformed  organ  is  fully  developed,  or  during  its  development,  it  can 
be  understood  that  the  peritonitis  may  have  been  instrumental  in  its 
pathogenesis.  Since  the  genital  organs  are  late  in  developing,  it  is 
very  probable  that  many  of  their  anomalies  (absence  of  fusion  of  the 
Miillerian  duets,  etc.)  may  be  due  to  peritonitic  bands  and  adhesions. 
Anomalies  in  the  position  of  the  intestines  and  other  abdominal 
organs  may  possibly  be  due  to  the  same  cause ;  Init  it  is  veiy  doubt- 
ful whether  the  situs  inversus  visccrum  which  e.xisted  in  Gessner's 
ease  {C'cntrlU.f.  Gynak.,  xx.  279,  1896)  can  be  so  explained.  Per- 
foration of  the  intestine  has  been  met  with  (G.  Eesinelli,  Ann.  di 
ostet.  e  ginec,  xxi.  89,  1899),  liut  whether  as  cause  or  effect  of  the 
peritonitis  is  not  known.  It  is  impossible  to  foretell  how  far-reaching 
maj'  be  the  ettects  of  foetal  peritonitis  upon  postnatal  life,  especially 
if  the  generative  organs  come  to  be  affected ;  but  this  is  a  subject  to 
which  I  have  already  referred  {ride  p.  25).  Among  the  many  changes 
which  have  been  traced,  with  some  show  of  probability  to  antenatal 
peritonitis,  is  congenital  obliteration  of  the  bile-ducts ;  and  to  that 
interesting  pathological  state  I  must  now  devote  a  page  or  two. 

Congenital  Obliteration  of  the  Bile-Ducts. 

Among  the  services  which  John  Thomson  has  rendered  to  a 
proper  understanding  of  the  diseases  of  infancy  must  be  reckoned  his 
work  on  congenital  obliteration  of  the  bile-ducts  (Trans.  Edinh.  Ohst. 
Soc,  xvii.  17,  191,  1891-2;  Allbutt's  System  of  Medicine,  iv.  253, 
1897).     What  follows  is  almost  entirely  a  presentment  of  his  views. 

Congenital  obliteration  of  the  bile-ducts  may  be  defined  as  an 
antenatal  lesion  of  the  bile-ducts,  of  practically  unknown  origin, 
leading  to  obliteration  of  their  lumen,  and  accompanied  by  biliary 
cirrhosis  of  the  liver,  causing  the  supervention  of  jaundice  early  in 
neonatal  life,  and  entailing  early  postnatal  death.  Eighty  cases  or 
so  have  been  recorded,  and  with  regard  t(j  them  all  the  physician  has 
been  compelled  to  confess  therapeutic  failure. 

There  is  little  or  nothing  that  is  special  in  the  clinieal  history 
of  the  pregnancy  which  ends  in  the  birth  of  an  infant  with  this 
anomalous  state  of  its  bile-ducts.  The  mother  does  not  seem  to  have 
suflered  in  any  way.  The  father  also  has  usually  been  healthy. 
There  is  an  exception,  however,  to  the  above  general  statement, 
namely,  the  occm-rence  of  family  prevalence,  often  to  a  very  remark- 
alile  degree ;  for  as  many  as  se\'en  or  even  ten  cases  of  infantile 
jaundice  due  to  this  lesion  of  the  bile-ducts  have  heen  observed  in 
one  famil)'. 

The  symptoiiiatolof/y  is  at  the  time  of  birth  practically  nil ;  but  in 
a  few  days  jaundice  of  a  more  marked  and  persistent  type  than  the 


364  AN'rHNAI'AI.    I'AIIIOI.OC'*'    AM)    IIVdll'.NK 

iinliiuii  V  icicrus  lU'diiaLoium  scl.s  in,  iuul  soon  the  stools  are  observed 
to  Ije  wliite  in  colour,  tlie  precedini;  motions  iiaving  consisted  of 
normal  <lark  nicconiiun.  Sometimes  it  would  seem  tlial  the  stools 
were  white  from  the  l)eginning.  The  jaundice  often  becomes  very 
dee]),  and  usually  persists  till  the  fatal  termination  of  the  case. 
There  may  be  hiematemesis  or  mel;ena  or  omphalorrhagia;  and  in 
other  cases  the  hicmon-hagic  tendency  is  revealed  liy  the  occurrence 
of  subcutaneous  ecchymoscs,  or  of  epistaxis.  The  lucmorrhage  may  be 
tlie  cause  of  early  death,  but,  if  the  infant  pass  this  danger  safely,  life 
is  usually  prolonged  for  some  months,  and  then  is  terminated  not 
infrequently  by  an  accidental  complication.  There  is  some  emaciation 
(although  often  this  is  inconsiderable)  before  the  close,  and  convul- 
sions may  also  occur.  There  is  deep  liile-staining  of  the  urine,  and 
constipation  is  the  rule. 

The  morbid  anatoiiui  of  these  cases  is  extremely  interesting.  The 
liver  is  usually  enlarged ;  it  has  an  uneven  surface  and  a  tough  con- 
sistence; and  it  is  of  a  dark  olive-green  colour.  Bands  of  til)rous 
tissue  form  a  network  throughout  it;  and  on  microscopic  examination 
the  lesions  are  found  to  be  those  of  liiliary  cirrhosis.  Many  of  the 
lesser  bile-ducts  are  plugged  with  inspissated  bile.  The  large  bile- 
ducts  and  the  gall  bladder  are  nearly  always  markedly  ah'ected,  but 
the  degree  of  the  affection  varies  greatly.  In  one  group  of  cases 
(usually  those  in  which  death  has  occurred  early)  the  ducts  may  .seem 
to  the  naked  eye  to  be  little  if  at  all  involved,  Imt  thickening  of  their 
walls  is  the  rule,  and  complete  obliteration  of  the  lumen  of  the  duct, 
with  fibrous  tissue  formation  around  it,  is  far  from  uncommon.  In 
the  most  advanced  examples  all  that  can  be  seen  of  the  duct  may  be 
a  strand  of  fibrous  tissue.  The  exact  site  of  the  oljliteration  varies 
greatly.  The  gall-bladder  may  contain  colourless  mucus,  or  very 
thick  bile,  or  a  gall-stone;  or  its  lumen  may  be  almost  obliterated  liy 
the  thickening  of  its  walls.  The  blood-vessels  of  the  liver  are  gener- 
ally normal;  the  spleen  is  enlarged;  but  the  peritoneum  is  usually 
unaffected,  save  in  cases  with  a  syphilitic  history,  and  in  tliem  thcrr 
are  adhesions  in  the  neighlwui'hood  of  the  bile-ducts. 

The  pailioloijy  of  the  disease,  for  the  reasons  so  often  stated 
(peculiarities  of  antenatal  environment,  ignorance  of  antenatal 
physiology,  etc.),  is  obscure.  It  would  seem  that  in  s(jme  cases 
chronic  progressive  inHammatiou  of  the  gall-bladder  and  ducts  must 
have  begun  very  early  in  f(Ptal  life  (third  month  of  antenatal 
existence);  these  are  the  cases  in  which  no  coloured  meconium  is 
passed.  In  others,  the  same  process  cannot  have  led  to  blocking  of 
tlie  ducts  till  much  later,  if  we  are  to  account  for  the  presence  of 
normal  meconium  in  the  bowel.  It  may  be  that  a  malformation  of 
the  ducts  caused  narrowing  of  the  available  lumen,  and  so  started 
the  whole  morljid  process  by  preventing  the  escape  of  the  bile ;  then, 
on  account  of  its  retention,  or  by  reason  of  irritating  properties 
possessed  by  it,  the  bile  sets  up  inflammatory  changes  in  its  con- 
taining vessels  with  resulting  biliary  cirrhosis  of  the  liver.  Again, 
it  is  possible  tliat  the  irritating  character  of  the  l>ile  may  be  the 
starting-point  of   the   chain  of   morbid  changes.      H.  IJ.  IJolleston 


CONGENITAL   OBLITERATION    OF  THE   BILE-DL(TS      ^05 

and  L.  11.  Hayne  {Brit.  iled.  Journ.,  i.  for  1901,  p.  758),  keeping  in 
mind  tbe  fact  that  poisons  reach  the  fcetal  economy  and  primarily 
the  liver  by  the  umbilical  vein,  believe  that  on  this  account 
some  of  the  irritating  material  (toxin,  poison)  will  at  once  set  up 
ordinary  portal  or  mnltilobular  cirrhosis,  and  that  the  rest  of  it  will 
pass  by  the  ductus  venosus  into  the  general  circulation.  Some  of 
the  poison  will,  however,  also  reach  the  Uver  by  the  hepatic  artery, 
be  excreted  into  the  intra-hepatic  bile-ducts,  and  set  up  cholangitis 
and  monolobular  cirrhosis.  In  this  way,  according  to  Eolleston  and 
Hayne  (loc.  cit.),  a  mixed  portal  and  biliary  cirrhosis  is  set  up;  the 
cholangitis  descends  to  the  larger  ducts,  and  gives  rise  to  an  oliliterat- 
ive  cholangitis  ;  thus  the  primary  changes  are  in  the  small  intra- 
hepatic ducts.  What  the  poisons  are  that  thus  reach  the  fcetus  is 
not  known,  but  there  is  some  evidence  that  they  are  not  syphilitic. 
The  marked  occurrence  of  family  prevalence  would  seem  to  show 
that  they  are  poisons  which  may  be  reproduced  in  several  successive 
pregnancies.  There  is  nothing  improbable  in  the  view  that  such 
poisons,  if  they  come  into  action  in  the  neofcetal  or  embryonic 
period,  may  produce  primary  defective  development  of  the  bile-duets, 
while  if  they  act  later  they  may  set  up  first  a  cirrhosis  and  then 
sulisequent  obliteration  of  the  ducts. 

The  diagnosis  of  the  disease  is  hardly  ever  made  until  some  days 
after  birth  have  passed,  when  the  persistence  of  what  was  regarded 
at  first  as  transient  icterus  neonatorum  excites  suspicion,  a  suspicion 
which  the  colourless  motions  and  bile-stained  urine,  and  latterly  the 
spontaneous  luemorrhages,  serve  to  confirm.  The  progjiosis  is  always 
of  the  gravest  kind,  and  with  regard  to  treatment  it  must  be  confessed 
that  it  is  nil — ihcra2}ia  nulla.  Manifestly,  if  the  whole  process  be 
due  to  poisons  reaching  the  foetus  from  the  mother,  the  only  hopeful 
line  of  treatment  will  consist  in  preventing  the  formation  of  these 
poisons  or  in  hindering  their  transmission ;  and  for  this  we  must  look 
to  the  as  yet  uudi.scovered  "  placental  tonic  "  and  to  other  forms  of 
antenatal  therapeutics.  It  would  in  the  meantime  be  of  great  import- 
ance to  find  out  the  natiu'e  of  the  transmitted  poisons  about  which  so 
much  speculation  has  taken  place. 

A  bibliography  of  the  subject  up  to  1896  is  given  l)y  Jolm 
Thomson  {loc.  cit.),  and  some  recent  references  have  been  added  l)y 
Eolleston  and  Hayne  {loc.  cit.). 

Congenital   Hypertrophic  Stenosis  of  the  Pylorus. 

Congenital  Hypertrophy  of  the  Pylorus  (or  Congenital  Gastric 
Spasm)  is  another  antenatal  condition  towards  the  elucidation  of 
which  John  Thomson  has  materially  contributed.  Besides  reporting 
three  cases,  he  has  advanced  an  ingenious  and  very  probable  theory 
of  their  i)athogenesis,  and  has  published  a  good  bibliography  of  the 
subject  {Scott.  Med.  Surg.  Journ.,  i.  511,  1896;  Edinh.  Hosn.Ecp.,  iv. 
116,  1896). 

Tiie  morljid  condition  of  the  pylorus  and  of  the  neighbouring  part 
of  the  stomach  wall  undoubtedly  exists  during  foetal  life ;  but  on 


366  ANTKNATAl.    TAil  lOI.OC^'    AM)    I  I'lCIF.NE 

account  of  the  priuciplo  of  potential  iiKuliiility  then  existing  it  gives 
rise  to  no  synqitoms  till  after  liirth  has  taken  place,  and  the  gastro- 
intestinal tiact  taken  mi  gieater  functional  activities.  Under  the 
name  of  "  scirrhus  of  the  stomach,  j)roliably  congenital,"  T.  Williamson 
of  Leith  seems  to  have  described  liypertropliy  of  the  pylorus  as  long 
ago  as  1841  {Month.  Journ.  Med.  >SV.,  Edinb.,  i.  23,  1841),  and  since 
then,  but  more  particularly  during  the  last  twelve  years,  more  than 
thirty  cases  have  Ijeen  reported  by  various  observers. 

With  regard  to  .si/iiijiloiiiatolvi/i/,  it  has  to  lie  noted  that  at  birth 
the  infant  shows  no  signs  of  illness  and  has  a  well-nourished  aii])ear- 
ance,  for  the  pathological  state,  although  in  existence,  has  not  begun 
to  produce  its  dire  ell'ects — latcl  anguis  in  hcrhd.  Tliere  is  a  record, 
in  some  cases,  of  maternal  sufi'ering  in  in'egnancy,  l)ut  this  is  not 
constant.  The  infant  begins  to  vomit  iu  from  two  or  three  hours  to 
two  or  three  weeks  after  birth  ;  at  first  the  vomiting  occurs  at  com- 
paratively long  intervals,  but  these  soon  diminish,  and  then  every 
attempt  to  swallow  even  a  teaspoonful  of  fluid  sullices  to  cause  the 
emptying  of  the  stomach.  The  ordinary  cau.ses  of  vomiting  are 
absent.  The  matters  l)rought  up  are  simply  the  swallowed  fluids 
mixed  with  mucus,  and  they  are  not  bile-stained.  The  emesis  may 
be  accomplished  with  great  force,  and  this  seems  to  be  more  markedly 
the  case  when  a  laige  quantity  of  Huid  is  given.  Ordinary  gastric 
sedatives  produce  no  good  effect,  although  gavage  may  cause  only 
a  temporary  amelioration.  The  fluid  being  prevented  from  passing 
from  the  stomach  into  the  duodenum,  lies  there  unabsorbed.  There 
is  usually  constipation,  and  the  motions  are  scanty.  IJy  alidominal 
palpation  the  hard  hypcrtrophied  pylorus  can  sometimes  be  left  in 
the  epigastric  region  as  a  movable  swelling,  for  the  abdonunal  walls 
are  lax  and  the  intestines  collapsed.  Finkelstein {Jahrh.f.  Kiiuhrhlh., 
xliii.  105, 1896)  was  able  to  make  out  this  physical  sign  of  the  disease. 
Infants  suffering  from  hypertrophy  of  the  pylorus  li\e  as  a  rule  not 
longer  than  three  mouths;  but  there  is  a  growing  belief  that  recovery 
sometimes  (F.  E.  Batten,  Lancet,  \\.  for  1899,  p.  1511)  occurs,  and 
that  for  treatment,  therefore,  there  may  perhai)S  exist  some  little 
spark  of  hojje — lateat  scintillula  forsan. 

The  morbid  (matomy  is  practically  limited  to  the  ))ylorus  and  the 
stomach  wall.  The  stomach  is  somewhat  enlarged,  and  its  wall  is 
thin  at  the  cardiac  end,  and  greatly  thickened  everywhere  else.  The 
pylorus  feels  almost  solid,  and  has  a  fusiform  or  even  an  oval  shape. 
The  pyloric  opening  seems  closed,  although  a  probe  can  be  passed 
through;  and  the  narrowing  is  due  to  the  hypcrtrophied  muscle. 
The  mucous  mendirane  is  tlirown  into  folds.  In  most  of  the  cases 
the  circular  muscular  bands  were  those  most  affected  by  tiie  hyper- 
trophy, but  in  one  instance  at  least  the  longitudinal  layer  was  very 
markedly  thickened.  The  mucous  and  submucous  coats  may  he 
quite  normal;  but  sometimes  the  latter  was  thickened  (e.g.,  in  (1.  F. 
Still's  third  case,  Trans.  Path.  Soe.  Lond.,  1.  88,  1899). 

The  patliogenrsi.'f  of  this  antenatal  disease  is  of  course  diflicult  to 
understand:  that  scarcely  rccpiires  saying.  It  would  seem  that  we 
must  consider  the  dilatation  of  the  stomach  and  oesophagus,  as  well  as 


CONGENITAL   GASTRIC   SPASM  367 

tlie  hypertrophy  of  the  pylorus  and  adjoining  gastric  wall,  to  be  due 
to  increased  but  disorderly  functional  activity  of  this  part  of  the  ali- 
mentary tract ;  it  would  also  appear  to  be  necessary  to  postulate  the 
occurrence  and  the  continuance  of  this  over-action  for  some  time 
before  birth.  As  Thomson  {loc.  cit.)  points  out,  there  is  no  evidence 
that  the  spasm  of  the  pylorus  is  due  to  a  local  lesion,  such  as  an 
ulcer  of  the  mucous  membrane,  nor  is  there  much,  if  anything,  to 
support  the  view  of  tlie  ])resence  of  an  irritating  fluid  in  tlie  stomach 
during  antenatal  life.  That  the  liquor  amnii  is  swallowed  by  the 
foetus  and  in  large  amount,  can  hardly  be  doubted  {ride  p.  153)  ;  but 
that  its  chemical  constitution  is  ever  so  altered  as  to  make  it  a  slow 
irritant  poison  to  the  ffftal  stomach,  while  it  is  of  course  possible,  is 
exceedingly  improbable.  We  are,  therefore,  led  to  accept  John 
Tiiomson's  explanation,  that  tlie  nervous  mechanism  of  the  stomach 
is  at  fault,  and  tliat  an  antagonistic  spasm  of  the  gastric  and  the 
pyloric  muscles  is  set  up  witli  resulting  hypertrojihy  of  both,  with 
stenosis  of  the  pylorus,  and  with  loss  of  power  of  absorption  of  the 
stomach.  To  say  that  the  congenital  hypertrophy  is  a  developmental 
overgrowth,  is  really  to  say  nothing  at  all,  nothing  at  any  rate  save 
what  has  been  inferred  in  the  name  of  the  disease.  The  acceptance 
of  Thomson's  theory  that  here  we  have  to  do  with  a  "  functional 
disorder  of  the  nerves  of  the  stomach  and  pylorus  leading  to  an  ill 
co-ordination,  and  tlierefore  an  antagonistic  action  of  their  muscular 
arrangement,"  introduces  some  novel  speculations  into  the  realm  of 
Antenatal  Pathology.  Of  course  it  is  possible  that  the  functional 
nervous  disorder  may  in  its  turn  be  due  to  "  faultly  development," 
yet  the  theory,  if  accepted  (and  I  do  not  see  how  one  can  do  other- 
wise than  accept  it),  introduces  the  idea  of  functional  disorders  into 
antenatal  pathology.  The  idea  thus  introduced  may  have  far- 
reaching  consequences ;  for  it  is  obvious  that  it  may  be  applied  to 
some  of  the  cardiac  malformations,  to  hyperti'ophy  of  the  urinary 
bladder  and  walls  of  the  colon,  and  even  to  enlargement  of  certain 
groups  of  skeletal  muscles.  Further,  it  may  not  only  tend  to  clear 
up  doubtful  questions  of  pathology  and  pathogenesis,  it  may  also 
suggest  new  methods  of  treatment,  and  instil  fresh  courage  into  the 
fainting  therapeutist,  and  rekindle  that  wonderful  "  scintillula "  of 
hope.  Batten  {loc.  cit.)  indeed  has  already  fanned  the  "  scintillula  " 
into  a  flame,  albeit  a  small  one,  by  suggesting  that  in  congenital 
gastric  spasm  the  infant  be  fed  by  a  nasal  tube  so  as  to  avoid  the 
starting  of  peristalsis  l>y  deglutition.  W.  Abel  {Milnchcn.  med. 
Wchnschr.,  xlvi.  1607,  1899),  also,  has  recorded  the  first  case  treated 
successfully  by  gastro-enterostomy  (Wolfler's  method). 

There  are  other  antenatal  diseases  of  the  digestive  organs  to 
which  reference  might  be  made,  such  as  congenital  hypertroph)-  of 
the  colon,  congenital  volvulus,  etc. ;  but  it  is  impossible  to  find 
space  for  more  than  the  four  types  given  above,  viz.  ascites, 
peritonitis,  jaundice,  and  gastric  spasm.  Of  these  the  first  is  a 
good  instance  of  a  foetal  disease  which  leads  to  great  delay  in  labour  ; 
the  second  is  important  on  account  of  its  possible  bearing  upon  the 


3G8 


ANTI'.NATAI.    1' All  1()1.(  Xl'i'    AND    1 1 YCI  I'AK 


production  of  lualldiiiiaiicnis  nf  the  generative  organs;  the  third  is 
an  example  of  tlial  potential  niorliidity  of  the  fcetiis  which  becomes 
so  real  after  Ijirth  ;  ami  the  fourth  has  an  interest  peculiarly  its  own 
because  of  its  probable  functional  origin.  Accompanying  the  fourth 
type,  also,  is  that  little  spark  of  liope  that  bespeaks  a  possible  method 
of  successful  treatment.  Let  us  leave  this  part  of  the  subject  with 
that  "scintilla"  shining  clieerily  ;  may  it  prove  to  be  im  ignis  fatuus 
or  Will-o'-the-wisii ! 


I 


CHAPTER    XXI 

Types  lit'  I<linj,,itliii'  Disi-asus  of  tlie  Kd'Uis  {n,nt.)  :  diseases  of  the 
Circulatory  Ajiparatiis  ;  Fu-tal  Eiiducarditis  —  Rulatioii  to  Couguiiital 
Cardiac  Anomalies,  Frequency,  Etiology,  Characters,  Diagnosis,  Associated 
Malformations,  Treatment  ;  Antenatal  Atheroma  ;  Congenital  Goitre,  Defini- 
tion, Illustrative  Cases,  Morbid  Anatomy,  Clinical  Results,  Treatment, 
Pathology,  and  Etiology  ;  Diseases  of  the  Kesjiiratoiy  System. 

Amoni;  the  idiopathic  diseases  of  the  i'o'tiis  must  be  reckoned  certain 
maladies  of  the  heart,  A'ascular  system,  blood  glands,  and  lungs,  such 
as  foetal  endocarditis,  congenital  atheroma,  congenital  goitre,  and  fcctal 
pneumonia.  Several  of  the  diseases  included  in  this  grouii  will,  no 
doubt,  yet  find  their  way  into  the  division  of  the  transmitted  morbid 
states ;  abotit  others  almost  nothing  has  been  securely  ascertained ; 
and,  taking  the  group  as  a  whole,  it  mnst  he  confessed  that  even 
more  than  the  nsual  ol:>scurity  belonging  to  antenatal  matters  hangs 
round  it.  Nevertheless  the  attempt  nuist  be  made  to  set  forth  our 
ignorance,  if  we  have  nothing  else  to  ofl'er. 

Foetal  Endocarditis. 

Fwtal  endocarditis  is  a  condition  to  which  reference  is  so  con- 
stantly made,  more  especially  in  connection  with  congenital  cardiac 
anomalies  and  malformations,  that  it  may  be  supposed  that  behind 
these  multiple  references  nuist  lie  a  large  number  of  well-ascertained 
facts.  But  this  is  very  far  from  the  truth.  Many  and  careful 
indeed  have  been  the  reports  of  cases  of  congenital  malformations 
of  the  heart,  and  fretal  endocarditis  is  referred  to  in  connection  with 
nearly  all  of  them ;  but  a  scrutiny  of  the  facts  leaves  the  reader 
impressed  with  the  indetiniteness  of  the  references  and  with  the 
hypothetical  nature  of  many  of  the  most  confident  assertions  which 
are  made.  Let  us  see  whether  anything  can  be  done  to  throw  light 
upon  this  matter. 

From  the  neofcetal  period  on  to  the  very  end  of  antenatal  life, 
the  formation  of  the  heart  may  lie  said  to  be  in  alieyance ;  it  is 
nearly  as  well  formed  at  the  beginning  of  the  second  month  of 
pregnancy  as  it  is  a  day  or  two  before  birth.  During  this  long 
period  it  grows  in  size  and  weight,  and  is  very  active  in  sending 
the  blood  round  the  circulation,  but  it  develops  scarcely  at  all ;  no 
great  changes  are  seen  in  it,  for  all  the  great  antenatal  developmental 
(processes  have  been  completed  before  the  end  of  the  second  month. 
'The  auricles  have  been  shut  off  from  the  ventricles  save  at  the  mitral 
and  tricuspid  openings,  and  the  right  side  of  the  heart  from  the  left 
24 


370  ANll'.NAlAl,    I'AIIIOI.OCV    AM)    IIYCII'.NK 

.save  at  the  fcnaiiicn  ovali;  :  llic  ]iiiliiiiiiiai  v  artery  and  the  anrta  liave 
lieen  dillereiiliated  and  liave  taken  on  tliuir  sejiarate  functions ;  and 
the  valvular  apparatus  is  coniplute.  Developnientally  the  lieart  is  as 
perfect  at  the  second  nioiitli  as  at  the  ninth.  Therefore  it  is  ex- 
tremely dillicult  to  understand  how  endncarditis  supervening^  hctwecn 
these  two  dates  can  produce  lualfonuations  which  are  evidently 
arrests  of  formative  processes  which  are  anterior  to  the  first  of 
these  dates.  On  the  other  hand,  it  must  lie  rememhered  that  a  i)art 
of  the  emhryology  of  tlie  heart  is  left  until  antenatal  life  is  over, 
and  is  acconiplislied  in  the  first  days  of  postnatal  existence;  1  refer 
to  closure  of  tlie  interauricular  cnniiiiunicatinn  and  to  uhlitcralion  of 
tlie  ductus  arteriosus. 

Now,  let  it  he  sujjposcd  tliat  endocarditis  attacks  liic  heart  at 
some  time  hetween  the  second  month  and  the  full  term  of  antenatal 
life.  The  affection  of  tlie  endocardium,  it  may  he  readily  adnntted, 
will  so  injure  the  vitality  of  the  heart  that  after  the  infant  is  l)orn 
there  may  he  a  delay  in  the  normal  closure  of  the  foramen  ovale  and 
the  ductus  arteriosus ;  in  this  way,  it  is  quite  conceivable,  may  be 
jtroduced  the  ordinary  form  of  con;4enital  cardiac  anomaly — a  jiatent 
foramen  and  a  pervious  ductus.  Perhaps  it  may  lie  necessary  to 
admit  that  the  endocarditis  sliall  have  specially  attacked  the  margins 
of  the  foramen  ovale  and  the  walls  of  the  ductus ;  but  the  a.ssump- 
tion  is  not  at  all  an  improbable  one.  Sometimes,  also,  it  may  be 
supposed  that  the  iuHammatory  process  will  lead  to  jircmature  closure 
of  the  foramen  or  ductus — a  matter  already  referred  to  {ride  pp.  235, 
293).  But,  it  may  be  asked,  is  endocarditis  coming  on  in  fcvtal  life 
not  instrumental  in  producing  any  other  of  the  malformations  of  the 
heart  met  witli  at  liirth  ?  It  is  eonceivalile  that  it  may  interfere  with 
the  rate  of  growtli  of  tlie  various  parts  of  the  heart,  although  its 
supervention  may  be  too  late  to  interfere  with  their  actual  formation 
In  this  way  may  be  produced  "congenital  stenosis  of  tlie  jnilmonary 
artery  and  aorta."  It  is  also  conceival)le  that  endocarditis  coming  on 
very  early  in  foetal  life  (ncofojtal  period)  may  interfere  with  the 
normal  completion  of  some  of  the  last  of  the  truly  formative  or 
embryogenetic  ])arts  of  tlie  development,  and  so  lead,  for  instance,  to 
persistence  of  the  interventricular  communication  or  to  anomalies  in 
the  separation  of  the  great  vessels  at  the  base  of  the  lieart.  IVIal- 
formations  due  to  the  persistence  of  embryogenetic  pliases  anterior 
to  the  neofoetal  period,  can  hardly  he  ascribed  to  fcetal  endocaiditis, 
unless,  indeed,  it  can  be  proved  that  this  disease  exists  or  can  exist  in 
these  early  periods. 

It  must  not  be  forgotten  tliat  there  is  another  aspect  of  this 
relation  of  fo'tal  endocarditis  to  cardiac  malformations.  It  iinist  be 
regarded  as  probalih-  tliat  iiiflammation  will  be  more  lialde  to  attack 
a  malformed  tlian  a  well-formed  heart.  Tlie  presence  of  malforma- 
tions will  predispose  to  foetal  endocarditis,  "  Le  vice  de  structure 
cree  la  vulnerabilite  "  (Mou.ssous,  in  Grancher's  Traiti!  dc  mal.  de 
Z'm/ffncf,  iii.,  p.  601,  18!)7). 

There  are,  therefore,  two  more  or  less  o]i]iosed  theories  regarding 
congi'iiital  cardiac  anomalies — the  teratological  and  tlie  ]iatliological. 


F(ETAL   ENDOCAHDiriS  371 

According  to  tlie  one,  they  are  instances  of  "errors  "in  formation; 
according  to  the  other,  they  are  tlie  results  of  fti;tal  endocarditis. 
But  the  degree  of  opposition  between  these  views  has  l}een  exagger- 
ated ;  indeed,  the  two  theories  are  not  incompatible.  The  structural 
defects  and  malformations  and  the  signs  of  foetal  endocarditis  may 
have  a  common  origin,  and  may  exist  side  by  side  a.s  evidence  of  a 
ciimmon  cause  which  has  begun  to  act  in  the  embryonic  period  of 
antenatal  life,  and  has  not  ceased  to  do  so  in  the  fretal  period. 

Tiie  subject  of  congenital  cardiac  anomalies  and  of  the  cyanotic 
condition  {morhiis  ciuruleiis)  which  so  often  accompanies  them  is  very 
large,  and  can  only  be  touched  ujion  here.  The  literature  is  given 
with  considerable  fulness  bj-  H.  Vicrordt  (Die  ani/ehorencn  Hcr-krank- 
heitcn,  Wien,  1898) ;  to  this  work  the  reader  who  wishes  to  explore 
this  interesting  dejiartment  of  medicine  is  referred.  I  have  tried  to 
indicate  the  relation  which  exists  or  probably  exists  between  foetal 
endocarditis  and  these  congenital  heart  cases,  and  in  a  strict  sense 
this  is  the  only  point  at  which  Fidal  I'athology  and  the  "  Congenital 
Hearts  "  come  into  contact.  For  it  must  be  borne  in  mind  that  an 
open  foramen  ovale  and  a  pervious  ductus  arteriosus  are  not  abnormal 
but  normal  during  fa'tal  life,  and  that  many  of  the  cardiac  malfor- 
mations which  are  present  in  the  fo'tal  period  of  antenatal  existence 
are  truly  emlnyonic  in  origin,  and  were  already  present  when  the 
embryo  became  a  fretus.  I'rom  my  present  standpoint,  therefore,  which 
is  that  of  Fn_^tal  Patliology,  the  subject  is  very  consideral)ly  narrowed 
down.  At  the  same  time  it  is  necessary  to  refer,  l:iut  with  Itrevity, 
to  certain  of  the  anomalies,  neonatal  as  well  as  embryonic  in  origin, 
with  which  fietal  endocarditis  is  associated. 

It  would  appear  that  fa^tal  endocarditis  is  relatively  common,  if 
one  accepts  the  evidence  afforded  by  the  presence  of  white  or  yellow 
thickenings  on  the  endocardium,  of  contraction  of  the  openings  or 
cavities  of  the  heart,  and  of  pathological  states  of  the  valves. 
Theoretically,  tliere  is  no  cause  to  doubt  the  frequency  of  fcetal 
endocarditis,  any  more  than  that  of  antenatal  hepatic  cirrhosis ;  for 
if  it  lie  granted  that  these  diseases  are  due  most  often  to  microbes, 
toxins,  and  poisons  coming  from  the  mother  to  the  f(etus  through  the 
placenta,  then  the  two  organs  first  reached  by  them  will  be  the  liver 
and  the  heart,  and  it  is  reasonable  to  look  for  lesions  in  these  viscera. 
In  this  way,  as  I  have  already  shown  {vide  pp.  182,  198,  208,  etc.), 
fevers,  tubercle,  syphilis,  alcoliolism,  and  other  morbid  states  in  the 
mother  reaching  the  fictns  through  the  umbilical  vein  set  up  cardiac 
and  hepatic  lesions  in  the  latter.  It  is  possible,  also,  that  some  cases 
of  foetal  endocarditis  arise  from  bacilli  and  toxic  products  manufac- 
tured liy  and  in  the  fcetal  organism  itself :  indeed,  if  we  hold  the 
infective  theory  of  causation  of  endocarditis,  it  is  necessary  to  accept 
this  supposition,  for  in  many  instances  the  mother's  health  in  preg- 
nancy has  been  good,  and  there  has  been  no  chance  of  a  microbic  or 
toxic  invasion  of  the  fcetal  tissues  by  way  of  the  placenta.  Some  of 
the  cases,  therefore,  are  really  of  the  natui'e  of  transmitted  maladies, 
while  others  are  idiopathic.  If  the  parts  in  the  heart  are  affected 
according  to  the  order  in  which  the  toxic  or  microbic  products  reach 


o72  ANJ'l'.NAlAI,    I'ATIIOI.OC;^     AM)    1 1 VC.Il'AK 

lliL'iii,  il  will  i'iill(j\v  tluit  the  ruraiiieii  oviili',  llic  uiilral  valvf,  the 
aortic  urilice,  the  trieiisiiiil  valve,  the  imhiioiiaiy  aiti'iy,  and  the 
(liictii.s  arteiiusiis  will  he  attacked  iii  that  order.  Al)Oiit  this  matter, 
however,  there  can  he  little  more  than  speculation  in  the  present 
state  of  our  knovvledf>;e.  Certainly,  narrowinjj;  of  the  ]iulnionary 
artery  would  appear  to  he  the  most  commonly  ohserved  congenital 
cardiac  anomaly,  and  instances  of  lesions  aflecting  the  tricuspid  valve 
are  not  wanting  (r//.,  Brindeau,  Ann.  dc  <jyni'c.,  xlv.  79,  189G ; 
Zariquiey,  llcv.  mens.  d.  mal.  dc  Vcnf.,  xii.  C20,  181)4);  hut  it  must  he 
liorne  in  mind  that  the  former  of  tliese  is  not  admitted  hy  all  or  even 
hy  many  writers  to  he  caused  hy  Icetal  endocarditis.  Nevertheless 
the  statement  is  made  with  ajijiarent  coniidence  that  the  right  side  of 
the  ftetal  heart  is  more  often  all'ected  with  inllammatiou  than  the 
left.  The  confidence  may  he  justified  ;  hut  it  ought  at  any  rate  to  lie 
l)orne  constantly  in  mind  that  the  fact  that  the  right  side  of  the 
heart  has  as  thick  walls  as  the  left  does  not  jirove  hypertrophy  of  the 
former  {vide  p.  111).  The  two  ventricles  may  have  walls  of  e<iual 
thickness  and  yet  he  normal  in  antenatal  life.  This  fact  and  others 
like  it  are  too  often  forgotten  or  neglected  in  drawing  conclusions  as 
to  the  effects  of  fo'tal  endocarditis.  Y.V.'W2\fCV  {Tnms.  Putli.  tSoc. 
Lond.,  xlviii.  51,  1896-7),  in  descriliing  the  heart  of  an  adult  showing 
calcification  of  the  tricuspid  valve,  stated  liis  helief  that  it  was  due 
to  intrauterine  endocarditis,  hut  lie  wisely  inserted  the  w'ord  "  jiroh- 
ably "  ill  the  statement ;  it  would  be  well  if  other  writers  were 
equally  guarded  and  made  more  use  of  "  prohahly,"  and  also,  pei-haps, 
of  "  possibly." 

Toetal  endocarditis  stands  out  prominently  among  the  other 
maladies  of  antenatal  life,  by  reason  of  the  fact  that  it  has  been 
diagnosed  before  birth.  H.  Padgett  (,Soutk.  J'rarti/ioner,  Kashville, 
xvi.  318,  1894),  for  instance,  detected  a  harsh  systolic  murmur  during 
auscultation  of  the  foetal  heart  in  pregnancy  ;  he  made  the  diagnosis 
of  mitral  heart  disease  of  the  unborn  infant,  and  confirmed  his 
diagnosis  by  the  examination  of  the  infant  after  birth.  Bellot 
(Bid/.  Soc.  anat.  dc  Par.,  5  s.,  ix.  757,  1895)  heard  a  murmur  l>cfore 
liirth ;  the  infant  was  born  in  a  state  of  cyanosis,  and  died  on  the 
fourth  daj-;  at  the  autopsy  a  single  vessel  (aorta)  was  found  arising 
from  the  base  of  the  heart  (from  the  right  ventricle).  J.  N.  Hall 
{Arch.  Pcdiat.,  xiv.  905,  1897),  in  his  communication,  also  gave  details 
of  cases  reported  l)y  Barth,  Hennig,  and  Christo])her ;  in  the  examjile 
reported  by  himself,  the  lesion  seemed  to  have  l)een  a  roughening  of 
the  lining  membrane  of  the  ductus  arteriosus,  for  the  murmur  which 
all'ected  the  first  sound  disappeared  ten  days  after  liirth.  In  esti- 
mating the  value  of  the  antenatal  diagnosis  of  fa'tal  heart  murmurs, 
the  possible  fallacy  of  the  uterine  souffle  must  not  be  forgotten  ;  but 
there  seems  to  be  sulHcicnt  evidence  to  justify  the  hope  that  along 
this  lino  advances  may  be  made  in  the  investigation  of  fo'tal 
maladies.  After  the  birth  of  the  infant  the  diagnosis  of  the  state  of 
its  heart  is  made,  of  course,  l)y  the  ordinary  clinical  methods;  and 
the  symiitomatology  and  ])hysieal  signs  of  congenital  heart  disca.se 
and   malformation    have   now  l.ieen   well   estal.ilished,  and  are  to  he 


FCETAL   ENDOCARDITIS  373 

fduncl  in  most  text-books  of  medicine  and  diseases  of  children.  The 
cyanosis  (early  or  late  in  appearing),  the  curious  polycythiemia  or 
return  of  the  blood  to  the  fcetal  state  as  regards  the  nuniber  of 
tlie  erythrocytes,  the  dyspncea  and  palpitation,  the  hypotherniy,  the 
elubliing  of  the  fingers  and  tlie  cardiac  murmurs  (usually  systolic), 
all  coml)ine  to  form  a  clinical  picture  which  is  easily  recognisable. 
It  must  lie  borne  in  mind  that  these  signs  and  symptoms  are  mostly 
due  not  to  the  endocarditis,  Imt  to  its  results  or  supposed  results, 
the  cardiac  malformations.  Difficulties  arise  when  the  attempt  is 
made  to  diagnose  the  exact  malformation  or  combination  of  mal- 
formations which  are  present  in  any  case ;  but  even  in  this  difficult 
department  of  medicine  considerable  progress  has  been  made.  The 
discussion  of  these  questions,  however,  would  lead  me  outside  the 
scope  of  this  work. 

It  is  a  noteworthy  fact  that  congenital  cardiac  anomalies,  and 
therefore  also  endocarditis  (if  we  accept  the  inflammatory  origin  of 
some  of  these  anomalies)  are  often  found  associated  with  malforma- 
tions of  other  parts  of  the  body.  Thus,  to  quote  from  a  recent 
contribution,  John  Thomson  and  W.  B.  Drummond  {Edinh.  Hasp. 
Rep.,  vi.  57,  1900)  found,  in  a  series  of  nine  cases  of  congenital  heart 
disease,  that  in  three  of  these  there  were  such  malformations  as 
hare-lip,  cleft  palate,  imperforate  anus,  malformation  of  external  ear, 
and  horse-shoe  kidney ;  in  another  case,  there  was  "  Mongolian " 
imbecility,  and  it  is  a  remarkable  fact,  noted  also  by  A.  G.  Garrod 
and  others,  that  this  type  of  imbecility  should  be  often  associated 
with  congenital  cardiac  anomalies.  All  these  fragments  of  evidence 
go  to  support  the  view  that  cardiac  anomalies,  foetal  endocarditis, 
and  malformations  of  other  parts  of  the  body  are  the  results  of  the 
action  of  a  common  cause,  and  that  the  ditterences  in  the  nature  of 
the  results  are  due  to  the  fact  that  the  cause  acts  at  different  times, 
and  consequently  upon  an  organism  in  ditterent  stages  of  develop- 
ment.    Series  implcxa  causarum — an  involved  chain  of  causes  ' 

I  was  recently  consulted  about  the  case  of  a  woman  who  had 
given  bu'th  to  an  infant  suffering  from  congenital  heart  disease 
(patent  foramen  ovale,  etc.),  which  survived  its  birth  eleven  months ; 
the  father  was  strongly  alcoholic  at  the  time  of  the  infant's  concep- 
tion and  for  two  years  previously,  but  the  woman  herself  was 
practically  a  total  aljstainer.  She  was  again  pregnant  (seven  weeks), 
and  I  was  asketl  regarding  the  probaljle  prognosis  as  regards  the 
oflspring.  The  husband's  habits  had  shown  distinct  signs  of  improve- 
ment, and  on  this  account,  and  because  the  mother  was  practically 
an  alistainer,  I  gave  a  more  hopeful  but  guarded  forecast  for  the 
infant.  I  have  recently  (Xovemlier,  1901)  heard  that  this  child  was 
healthy  and  free  from  cardiac  trouljle. 

Wliile  little  has  been  done  towards  the  antenatal  treatment  of 
congenital  cardiac  anomalies,  it  is  an  interesting  fact  that  apparently 
they  are  sometimes  recovered  from  after  Iiirth.  Evidence  supporting 
this  conclusion  is  supplied  by  John  Thomson's  case  {Arch.  Feeliat., 
xviii.  193,  1901);  possibly  similar  instances  might  lie  found  if  care- 
fully looked  for ;  possibly,  also,  antenatal  recovery  may  not  be  rare. 


374 


ANTENATAL    I'All  lOl.OC^     AND    IIVCIKNE 


Antenatal  Atheroma. 

Little  is  known  I'cu'iinliiiLi;  discuses  nf  the  lilduit  vessels  in  lu'tal 
life,  save  in  connection  with  the  clian<;es  which  they  underjro  in 
syphilis  (vide  p.  230).  Certainly  we  should  not  expect  to  find  morbid 
conditions  which  an;  ehai'actcristie  of  old  age  in  antenatal  life, 
nevertheless  Durante  (Bull.  Sue.  annl.  de  I'ur.,  6  s.,  i.  97,  1899)  has 
recorded  a  case  of  atheiMiua  in  the  infant  at  hirth.  The  child  was 
born  at  the  seventh  month,  and  died  a  fortnight  later  with  signs  of 
general  (edema  and  ]ieritonitis.  'The  heart  showed  no  lesions,  and 
there  was  no  pericarditis.  The  pulmonary  artery,  however,  had  hard 
walls  with  patches  of  considerable  density,  s\icli  as 
are  found  in  the  senile  aorta  ;  its  inner  surface  was 
white  and  smooth.  The  aorta  felt  uiuisually  rigid. 
The  microscopical  examination  of  the  heart  (endo-, 
peri-,  and  myocardium)  ga\e  normal  results:  but 
in  the  deeper  jxirtious  of  the  middle  coat  of  the 
pulmonary  artery  there  was  marked  fatty  degen- 
eration and  calcareous  infiltration.  The  aorta 
showed  similar  but  less  evident  changes.  In 
neither  vessel  was  the  intima  atfccted.  The 
changes  could  hardly  have  occurred  after  liirth, 
and  the  absence  of  signs  of  endocarditis  })recluded 
the  idea  of  postnatal  infection.  We  are  driven, 
therefore,  to  the  conclusion  that  atheroma  of  the 
aorta  and  ]iulmonarv  arlerv  mav  occur  in  antenatal 
life. 

Congenital  Goitre. 

Under  the  name  "  struma  congenita  '"  have  been 
lescribed  various  swellings  of  the  neck  found  in 
the  infant  at  birth.  Along  with  its  synonyms, 
"intrauterine  goitre''  and  "intrauterine  liron- 
cliocele,"  it  has  been  made  to  include  not  only 
enlargements  of  the  thyroid  gland  and  parathy- 

Vroids,  but  also  cervical  h3'gromata,  cervical  sjiiua 
bifida,  and  ranula.     The  name,  if  it  is  to  be  retained 
at  all,  ought  to  be  reserved  for  swellings  of  the 
p'iP,_  5g_  thyroid  gland  alone;  but  it  is  not  a.  good  term, 

and  might  be  abandoned  altogether  with  more  of 
profit  than  of  loss.  I  met  with  a  specimen  of  this  morbid  state  in 
1894,  which  is  represented  in  Fig.  55:  it  was  a  foetus  w"eigliing 
178  grms.,  born  between  the  fourth  and  fifth  months,  and  showing  a 
general  congestive  enlargenuMit  of  the  tissues  of  the  neck  between 
the  lower  jaw  and  the  manubrium  sterui ;  the  case  occurred  in  the 
practice  of  Dr.  E.  Coleman  I\Ioore,  and  the  parents  were  free  from 
any  cervical  enlargenunit.  T  have  recently  examined  another  casi'  of 
large  cystic  swelling  in  the  neck,  but  it  was  evidently  a  congenital 
hydrocele  or  hygroma,  and  not  at  all  of  the  same  nature  as  Dr. 
Coleman   Moore's  case. 


CONGENITAL   GOITRE  375 

During  the  last  fifty  years  a  considerable  number  of  observations 
of  congenital  enlargement  of  the  thyroid  gland  have  Ijeen  published. 
In  Edinburgli,  A.  Keiller  {Edinh.  Med.  and  Surg.  Journ.,  Ixxxii.  31, 
1855)  reported  a  case  in  which  there  was  a  large  irregularly  lobu- 
lated  swelling  in  the  region  of  the  thyroid  gland  in  a  new-born 
infant ;  the  child  had  presented  by  the  forehead,  for,  on  account  of 
the  cervical  tumour,  the  normal  Hexion  of  the  head  could  not  take 
place ;  neither  the  mother  nor  any  of  her  relatives  were  goitrous. 
A  somewhat  similar  case  was  described  by  J.  Y.  Simpson  {Month. 
Journ.  Med.  Se.,  xx.  350,  1855) ;  it  was  the  tenth  child  of  a  non- 
goitrous  woman  ;  it  was  born  somewhat  prematurely,  and,  on  account 
of  the  compression  of  the  trachea,  died  in  eight  hours ;  tlie  thyi-oid 
gland  was  nearly  as  large  as  a  hen's  egg,  and  caused  delay  in  labour 
and  an  alniormal  presentation  (forehead);  all  parts  of  the  thyroid 
were  equally  affected,  and  the  gland  surrounded  the  trachea  almost 
entu-ely ;  its  vesicular  cavities  seemed  not  only  increased  in  number 
but  enlarged  in  size  also,  and  the  septa  between  them  were  con- 
siderably thickened ;  and  the  thymus  gland  and  adrenals  appeared  to 
be  normal.  A.  E.  Simpson  (Glasgow  Med.  Journ.,  3  s.,  i.  181,  1866-7) 
also  met  with  an  instance  of  congenital  "  g<:)itre  "  in  a  case  where  the 
mother  had  been  taking  chlorate  of  potash  in  pregnancy,  with  a  view 
to  the  prevention  of  miscarriages  and  premature  labours ;  the  anterior 
fontanelle  presented  and  labour  was  delayed ;  the  thyroid  seemed  to 
be  equally  enlarged  in  its  isthmus  and  lateral  lobes ;  at  first  there 
was  ditficulty  in  respiration  and  deglutition,  but  at  the  age  of  four 
months  the  tumour  was  much  shrunken  and  the  child  (a  male) 
appeared  healthy. 

In  addition  to  these  cases,  published  in  Edinlmrgh  and  Glasgow, 
there  have  been  others  reported,  more  especially  on  the  Continent. 
Among  these  may  be  mentioned  the  observations  of  E.  W.  Crichton 
(Fdinb.  Mrd.  Journ.,  ii.  149,  1856),  of  V.  Betz  (Ztschr.  f.  rat.  Med.,  ix. 
233,  1850),  of  A.  Besnard  {Afeel.  Cor.-Bl.  layer  Aerzte,  viii.  806,  1847), 
of  Diener  (Schweiz.  Ztschr.  f.  Med.  Chir.  v.  Geburtsh.,  Zurich,  455, 
1848),  of  Malgaigne  {Eev.  mi'd.  chir.  de  Far.,  ix.  368,  1851),  of  Dan- 
yau  (Gaz.  d.  hop.,  xxxiv.  78,  1861),  of  Bcraud  and  Danyau  {Bidl.  Soc. 
de  chir.  de  Far.,  2  s.,  ii.  108,  1862),  of  0.  Spiegelberg  (Wiirzb.  med. 
Ztschr.,  V.  160,  1864),  of  Frobelius  (St.  Fetersb.  med.  Ztschr.,  ix.  175, 
1865),  of  L.  Porta  (Gior.  di  ancd.  cjisiol,  iii.  37,  1866),  of  W.  Miiller 
(Jenaischc  Ztschr.  f.  Med.  u.  Neiturw.,  vi.  454,  1871),  of  Efiug  (Deutsche 
Ztschr.  f.  Thiermed.,  i.  349,  1875),  of  L.  Mayer  (Beitr.  z.  Geburtsh.  n. 
Gyndk.,  iii.  86,  1874),  of  H.  Lohlein  (Ztschr.  f.  Geburtsh.  u.  Gyndk.,  i. 
23,  1875),  and  of  others.  C.  Taruffi  (Sulle  strume  congenitc  deUei 
tiroide,  Bologna,  1892)  gathered  together  a  great  many  of  the  pub- 
lished cases  and  considered  the  whole  subject,  as  did  also  E.  Demme 
(in  Gerhardt's  Handbueh  der  Kinderkrankheiten,  Band  iii..  Heft  ii.  388, 
1878),  Schenk  (Dissert.,  Heidelberg,  1891),  and  some  others. 

The  enlargement  of  the  thyroid  varied  much  in  different  cases, 
being  sometimes  of  the  size  of  a  hen's  egg  and  sometimes  as  large  as 
a  fcetal  head  (A.  Billig,  Dtsscr^.,  Heidelberg,  1892) ;  its  weight  has 
exceeded  100  grms.     The  enlargement  may  affect  all  the  parts  of  the 


r.TG  ANTKNATAI.    I'Al'l  l()I.()(  ;Y    AND    IlVdIKNK 

gland,  but  cases  have  l)ecii  leiioiled  in  wliicli  one  lobe  only  was 
affected.  In  stiuctme  the  tumour  may  he  (1)  of  an  adenomatous 
type,  but  that  is  not  the  commonest  form  ;  (2)  it  may  be  made  up  of 
an  increase  in  the  vesicular  substance  of  the  gland  (parenciiymatous 
type),  and  may  t lien  show  colloid  or  true  cystic  changes;  and  ('■'>)  it 
may  be  of  the  ctjugestivo  tyi>e.  Sometimes  tiiere  is  a  concomitant 
enlargement  of  the  thymus  (!•".  Weber,  Ikitrdgi-  z.  jKiih.  Anat.  der 
Ncwjchornen,  Lief.  ii.  84,  Kiel,  1852);  sometimes,  also,  the  thyroid 
tumnur  contains  cartilaginous  or  my.Komatous  tissue. 

The  effects  of  fietal  goitre  become  apparent  as  soon  us  ]iulmonary 
respiration  is  rendered  necessary,  for  tlie  swelling  usually  compresses 
the  trachea  so  as  to  impede  breathing,  or  else  ])roduces  a  similar  result 
by  pressure  on  the  nerves  in  llie  ueighljourliood.  ]lef(U'e  birth  the 
life  of  the  feetus  is  not  threatened ;  but  an  abnormal  presentation 
(forehead,  face)  may  be  produced,  and  so  delay,  and  possibly  infantile 
death  during  labour  be  brought  about.  After  birth,  if  the  first  dangers 
from  difticulty  in  establishing  respiration  are  overcome,  the  swelling 
in  the  neck  tends  to  diminish  in  size,  and  may  almost  entirely  disappear. 
This  tendency  to  wither  away  must  be  taken  into  account  in  estimating 
the  result  of  treatment,  as  in  the  case  reported  by  A.  Mossi'  and 
Cathala  {Bull.  Acad.  Med.,  3  s.,  x.xxi.x.  420, 1898),  in  which  a  goitrous 
mother  who  was  nursing  her  goitrous  infant  was  treated  with  dry 
thyroid  extract  with  an  apparently  beneficial  eflect  upon  the  infant. 
A  more  radical  method  of  treatment  was  that  adopted  by  Polo.sson 
and  reported  l)y  Genevet  {Lyon  nu'd.,  xcii.  30l'>,  1899) :  the  infant  was 
the  child  of  a  goitrous  mother,  and  was  born  in  a  state  of  apparent 
death ;  it  was  resuscitated  with  great  difliculty,  and  still  showed 
marked  dyspna3a  and  noisy  respiration  ;  a  tumour  was  discovered  in 
the  neck  of  doubtful  nature :  an  incision  was  made  in  the  middle  line 
and  a  fairly  large  goitre  was  exposed ;  the  tumour  was  pulled  gently 
out  of  the  wound  (exothyropexy),  and  left  outside  without  any  dressing 
to  atrophy  ;  and  Polosson  intended  to  hasten  this  process  if  necessary 
by  punctures  with  the  thermo-cautery.  In  Brosin's  case  {Centrlhl.f. 
Gyniik.,  xviii.  1170,  1894)  operative  treatment  did  not  succeed. 

In  considering  the  etiology  and  pathogenesis  of  so-called  con- 
genital struma,  we  meet  with  two  well-ascertained  facts:  one  is  the 
birth  of  goitrous  infants  by  goitrous  mothers,  and  the  other  is  the 
occurrence  of  cases  in  which  the  infant  has  an  enlargement  of  the 
thyroid  gland,  and  yet  neither  the  mother  nor  father  nor  any  other 
relative  suffers  or  has  sullered  in  a  similar  manner.  This  morbid 
state,  therefore,  would  a])pear  to  have  an  equal  claim  to  admission 
among  the  transmitted  and  the  idiojiathic  diseases  of  the  fietus;  or 
rather,  if  the  statistics  of  1  )emme  {op.  cit.)  are  had  regard  to,  the  malady 
would  be  placed  with  those  that  are  transmitted.  The  condiliun 
would  seem  to  be  most  common  in  the  localities  in  which  goiire  is 
most  common ;  in  Switzerland,  for  instance,  Demme  reported  (142 
cases,  and  53  of  these  were  congenital.  Among  the  53  congenital 
ciises  there  were  14  in  which  l)oth  ])aienls  were  goitrous,  23  in  which 
the  mother  alone  w'as  affected,  and  10  in  which  l>oth  jiarents  were 
exempt  from  the  malady.     Tlie  congenital  cases  ditl'cr  from  those  in 


COXGEMTAL   (iOITRK  377 

the  adult  in  showing  a  preference  for  the  male  rather  than  for  the 
female  sex.  It  is,  after  all,  absolutely  necessary  for  us  to  know  more 
aliout  the  pathogenesis  of  goitre  in  general  before  we  can  hope  to 
solve  the  problem  of  its  transmission  or  non-transmission  from  parent 
to  child.  Possibly  some  of  the  cases  in  which  there  is  no  history  or 
evidence  of  a  family  tendency  to  goitre  may  be  really  instances  of 
cystic  enlargement  of  other  structures  in  the  neck  {ride  C.  Tarutii, 
op.  cif.). 

It  is  not  my  intention  to  give  any  space  here  to  the  consideration 
(if  the  idiopathic  diseases  of  the  lungs  and  pleura  in  the  foetus.  I  have 
already  referred  to  the  state  of  the  lungs  in  sepsis  (p.  217),  in  syphilis 
(p.  234),  and  in  tubercle  (p.  208);  and  after  one  has  named  these 
occasional  morbid  conditions,  as  well  as  the  pneumonia  which  arises 
from  pulmonary  infection  during  labour,  it  may  indeed  be  doubted 
whether  there  ai-e  any  diseases  of  the  fcetal  lungs  which  are  really  to 
Ije  regarded  as  idiopathic. 


CllArTEU    XXII 

Types  nf  Idioimthic  Diseases  of  the  Kn'tus  (amt.)  :  Diseases  (if  tlie  I'l'iiiarv 
Apparatus :  Fcetal  Nephritis,  Distension  of  the  lihidder,  Ilyiieitroiihic 
Dihitation  of  the  Blarkler,  Hydronephrosis,  Cystic  Degeneration  of  the 
Kidneys:  Diseases  of  the  Genital  Orj^ans  :  Conf;enital  Prola])se  of  the 
Uterus  ;  Diseases  of  the  Nervous  System  :  Hydrocephalus  ;  Little's  Disease  ; 
Congenital  Chorea  ;  Friedreich's  Ataxia  ;  Thonisen's  Disease  ;  Congenital 
Cloudini;  of  the  Cornea. 

Ix  this  Chapter  I  ,L;allier  together  some  of  tlie  reiiiaiiiiiig-  types  of 
idiopathic  disease  in  the  fcotus,  although  it  mtist  be  freely  admitted 
that  they  are  scarcely  "  tj'pical,"  and  that  they  are  only  doubtfully 
idiopathic.  About  some  of  them  very  little  is  known,  and  al>out 
others  tlie  information  which  we  possess  is  chiefly  obstetrical,  and 
arises  from  the  delay  in  labour  which  they  cause  by  the  alteration 
in  the  size  of  the  fn'tus  which  they  produce.  A  short  chapter  is 
therefore  all  that  need  l)e  set  apart  for  their  consideration. 

Diseases  of  the  Urinary  Apparatus. 

I  have  already  (ji.  IG'2)  adduced  evidence  to  slmw  tiiat  the 
urinary  organs  are  functionally  active  during  fcetal  life ;  and  it  may 
therefore  be  concluded  that  they  will  be  subject  to  diseases  during 
this  period.  Cases,  also,  are  actually  on  record  which  demonstrate 
this.  Some  of  these  produce  dystocia  by  reason  of  the  alidoniinal 
distension  which  they  give  rise  to,  and  about  them  a  good  deal  of 
information  is  forthcoming :  others  do  not  cause  any  special  enlarge- 
ment, and  have  been  little  investigated.  In  the  latter  group  fo'tal 
nephritis  must  l)e  placed.  Some  few  facts,  however,  are  kiiciwn  with 
regard  to  it,  and  these  may  now  be  stated. 

Fcetal   Nephritis. 

Allusion  has  already  been  made  to  the  changes  in  the  kidneys  in 
fd'tal  syphilis,  and  it  has  been  stated  that  possibly  in  some  instances 
of  general  foetal  dro])sy  the  starting  point  of  the  morbid  process 
may  have  been  a  renal  intlammation :  but  there  is  some  evidence 
also  that  nephritis  may  arise  in  antenatal  life  in  an  idiopathic 
fashion.  In  a  case  which  I  examined  and  reported  on  some  years 
ago  (Dixrancn  of  the  Fidmt,  ii.  15,  189.")),  the  prcMuature  infant  of  a 
woman  suil'ering  from  bronchitis  and  imeumonia  developed  (cdenia 
of  the  lower  limlis  and  trunk  within  a  few  hours  of  birth,  and  died 


FCETAL  NEPHRITIS  379 

in  two  days ;  during  his  brief  life  he  passed  no  urine  so  far  as  could 
be  ascertained.  At  the  post-mortem  a  condition  of  intense  con- 
gestion of  the  kidneys,  and  more  especially  of  their  cortex,  was 
found  ;  under  the  microscope,  cloudy  swelling  of  the  cells  of  the 
urinary  tubules  and  small  cell  infiltration  of  the  Malpighian  bodies 
was  discovered,  changes  which  pointed  to  tubular  and  glomerular 
nephritis.  Of  course  it  is  possible  that,  in  this  instance,  the  renal 
alterations  were  entirely  postnatal ;  some  evidence  in  favour  of  an 
antenatal  origin  of  the  nephritis  was  present,  but  it  was  not  conclusive. 
Stronger  proof,  however,  is  forthcoming,  for  in  March  of  the  present 
year  (1901)  I  received  from  i)r.  Henry  Ashby  of  Manchester  the 
notes  of  a  case  whicli  seemed  to  have  been  one  of  undoubted  fostal 
nephritis.  The  case  was  that  of  an  infant,  twenty-one  days  of  age, 
intensely  dropsical  in  the  face,  limbs, and  alidomen ;  it  died  in  ura-mic 
convulsions ;  and  the  post-mortem  examination  revealed  the  presence 
of  kidneys  showing  marked  chronic  or  subacute  nephritis  in  the  "  small 
wliite "  stage.  Under  the  microscope  the  organs,  which  presented 
tlie  ftt'tal  loliulations  very  plainly,  showed  blood  and  fibrinous  casts, 
dilated  convoluted  and  straight  tubules,  fatty  epithelium,  and  com- 
mencing fibro-cellular  changes  around  the  glomeruli  and  between 
the  tulniles.  The  mother  was  a  healthy  woman,  who  had  not  suffered 
from  nephritis,  and  there  was  no  history  of  alcoholism,  syphilis,  or 
any  form  of  poisoning.  During  the  life  of  the  child  little  urine  was 
passed ;  the  dropsy  appeared  on  the  second  day  of  life.  I  agree  witli 
Ashby  tliat  it  is  very  probable  that  this  was  an  instance  of  fo;'tal 
nephritis ;  further,  in  the  absence  of  any  other  evidence,  it  must  be 
regarded  as  idiopathic  foetal  nephritis. 

As  has  been  already  pointed  out,  albuminuria  in  the  new-l)orn 
sometimes  occurs  even  when  the  mother  has  not  suffered  from 
nephritis  or  eclampsia;  and  this  neonatal  albuminuria  apparently 
does  not  always  or  often  signify  permanent  renal  lesions.  It  may  mean 
nothing  more  than  an  imperfect  development  of  the  renal  epithelium. 
On  this  question  Hugo  Eibbert's  article  (Arch.  f.  path.  Anat.,  xcviii. 
527,  1884)  may  he  consulted  with  profit.  Nevertheless,  the  occa- 
sional occurrence  of  nephritis  which  has  begun  in  the  foetus  while 
still  in  utero  cannot,  I  think,  be  doubted.  Along  this  line  most 
useful  pathological  investigations  upon  still-Ijorn  infants  might  be 
made.  The  relation  of  the  f(etal  renal  lesions  to  placental  morbid 
states  is  also  well  worthy  of  study. 

Distension  of  the  Bladder. 

Many  cases  are  on  record  in  which  labour  was  delayed  by  an 
enlargement  of  the  fatal  abdomen  caused  by  an  enormously  distended 
urinary  bladder.  These  cases  must,  I  think,  be  separated  from 
those  in  which  the  bladder  is  hypertrophied  as  well  as  somewhat 
dilated.  In  the  former  the  morbid  state  is  evidently  a  distension  of 
the  fo'tal  bladder  on  account  of  grave  malformations  of  the  urethra 
and  external  genitals ;  in  the  latter  no  such  explanation  is 
feasible,   and   the  condition   is   rather   to   be  comxmred   with    con- 


380  AXTF.NAIAI.    1' A  11  lOI.OC  1^     AM)    IIYCII-.NF, 

goiiilal  liy]icrtni]iliy  'if  tlio  ]iyliinis  and  L'iiliii;j;('im'iit  of  the  colon. 
A  few  Words  aiv,  all  that  aic  iiccessai y  with  i('.i,'ard  to  the  fonner 
anomaly. 

The   dislen.siiiii    of  th(^    Madder    with    iii'ine    may   reaeh  a  trnly 
enormous  degree,  so  that  the  head  and  lindis  of  the  fo-tns  apjicar  a.s 
insiynilieant  appendages  to  the  large  glohular  trunk.     The  striking       || 
deformity  thus  produced  was  very  evident  in  the  specimens  of  F.      L 
Fabris  (Ann.  dl  oxtd.,  xvii.  329,  ISDo),  C.  Taruffi  (Mem.  d.  r.  Accad.      \' 
d.  nc.  d.  ftitit.  di  IJoloi/na,  5   s.,  iv.  73,  1894),  V.  Frascani  (A//,i  Cowj.       j^ 
(len.  d.  Asfi.  vied.  Hal.,  Siena,  xiv.   538,  1891),  (1.  Schwv/.er  {Arclt.  f.      '| 
'Gi/naek,  xliii.  .•'.33,  1893),  A.  Mueller  (ddd.,  xlvii.  130,  1894),  AV.      'i 
Westphal  (Dissert.,  Konig.slierg,  i.  Pr.,  189G),  Kristellcr  (Mimntsehr.        I 
f.  Gelmrtsk.  v.  Francnh:,  xxvii.    1G5,   1866),  and  many  others.     In       .1 
F\il)ris'  case,  for  instance,  the  fcetus,  which  was  born  at   the  ninth       [ 
month,  measured  45  cms.  in  length,  and  had  a  greatly  enlarged  ab-       \t 
dominal  circumference  (exact  measurement  not  given).     The  bladder       ' 
contained   2i  litres  of  fluid.      The  undjilical  cord  appeared   to   lie       '  | 
normal,  and  was  inserted  upon  the  greatly  distended  abdomen  in  the       '  i 
usual   way.     There  were  no   traces  of  external   genital   organs,  and         I 
there  was  also  atresia  ani ;  from  coccyx  to  pubes  the  .skin   wa.s  un-       ''<■ 
broken  by  any  depressions,  fissures,  or  elevations.     In  the  alidominal       | 
cavity  was  a  large  sac  with  a  circumference  of  40  cms. ;  in  its  upper       ! 
part  the  sac  was  adherent  to  the  diaphragm,  liver,  and  stomach  ;  its 
walls  were  rather  tliick   when  contrasted   with  the  thinned  out  alj- 
donnnal  parietes.       On  the    inner  aspect  of  the  sac   (the    bladder)       ; 
could  be  seen  the  openings  of  the  two  ureters  which  were  pervious, 
but  there  was   no  indication  of  the  internal   orifice  of  the   urethra       ;g 
.save  a  slight  depression.     The  rectum  en<led  blindly  in  an  enlarge-       jl 
ment  which  adhered  to  the  left  side  of  the  distended  bladder.     The       * 
kidneys  and  ureters  had  their  normal  appearances.     There  were  no 
traces  of  vesicuLe  seminales,  vasa  deferentia,  prostate,  urethra,  and 
interaal  genitals.     Tlie  li'juid  found  in  the  bladder  was  clear,  trans- 
parent, limpid,  and  had  a  specific   gravity   of    1007.      There   was 
marked  hydramnios  in  this   case,  and  the  labour  was   delayed  and 
had  to  be  terminated  artificially  liy  forceps  and  puncture  "f   the 
abdomen. 

The  al)0ve  case  may  be  taken  as  a  type  of  this  variety  of  fietal 
disease,  although  in  several  of  its  details  it  differs  from  other 
instances.  Sometimes,  for  example,  there  is  scarcity  instead  of 
abundance  of  liquor  amnii,  and  there  are  also  sometimes  other  kinds 
of  concomitant  malformations,  e.g.  anomalies  of  the  limbs,  horse-  ■ 
shoo  kidneys,  hy]iosjiadias,  ui'cteral  dilatations,  etc.  In  Schwyzer's  I 
specimen  (loe.  cit.)  the  fluid  in  the  fcetal  liladder  is  .said  to  have 
reached  the  large  amount  of  01  litres.  Iii  these  cases  the  dislen.sion 
of  the  foetal  bladder  is  evidently  the  result  of  the  concomitant  mal- 
formations ;  they  are  not,  therefore,  strictly  to  be  regarded  as  diseases, 
hut  as  morbid  conditions  due  to  teratologieal  states.  In  this  respect 
thev  dill'er  from  the  cases  now'  to  be  referred  to. 


DILATATION    OF   THK    BLADDKR  :J81 

Hypertrophic   Dilatation  of  the  Bladder,   etc. 

Ill  181)4  I  received  froui  l)r.  W.  Cardy  Blucka  fn'tus,  wliich  showed 
very  clearly  a  state  of  hypertrophic  dilatation  of  the  bladder  and  ureters 
along  with  hydronephrosis  (176).  The  mother  was  37  years  of  age  and 
a  6-para ;  and  the  five  previous  children  were  all  alive,  but  delicate 
and  rachitic.  In  the  present  iu.stance,  labour  came  on  at  the  eighth 
month  ;  the  presentation  was  the  vertex,  the  position  L.O.  A.;  the  labour 
lasted  eight  hours,  and  the  pains  were  infrequent  and  feeble ;  the 
amount  of  liquor  amnii  was  estimated  at  not  more  than  one  fluid 
ounce  (oligohydramnion).  The  father  was  a  strict  vegetarian,  and 
confined  his  family  chiefly  to  milk  and  bread.  The  infant,  a  male, 
was  still-born;  it  weighed  5i  lbs.,  and  had  talipes  varus  of  both 
feet  and  drop-wrist  of  the  right  hand.  A  rounded  tumour  could  be 
felt  on  the  left  side  in  the  abdomen.  When  the  abdomen  was  opened 
the  bladder  was  seen  to  be  greatly  distended,  as  were  also  the  ureters  ; 
in  fact,  the  latter  were  enormously  dilated  and  convoluted.  There 
was  also  bilateral  hydronephrosis,  but  the  renal  change  was  more 
marked  on  the  left  than  on  the  right  side.  Fluid  regurgitated  easily 
from  the  bladder  into  the  left  ureter,  but  not  into  the  right.  The 
urethra  was  found  to  be  occluded  near  to  the  meatus  urinarius. 
Further  examination  showed  the  left  ureter  to  be  sacculated ;  it  was 
impossible  to  pass  a  probe  along  it,  on  account  of  a  series  of  at  least 
nine  folds  of  the  mucous  membrane  which  had  free  edges  and  formed 
j)0uches.  The  right  ureter  showed  similar  but  less  marked  changes. 
The  left  kidney  contained  numerous  small  cysts,  but  its  pelvis  was 
not  dilated.     The  bladder  wall  was  thick. 

I  have  had  an  opportunity  of  examining  another  specimen  not 
unlike  the  above.  Notes  of  this  case  were  pubilished  by  I)r.  C.  Mabel 
Blackwood  {Minh.  Med.  Journ.,  xli.  919,  189G).  The  mother  of  the 
infant  was  healthy,  and  had  given  birth  to  two  healthy  children.  In 
her  third  piegnancy  the  labour  was  tedious  from  uterine  inertia, 
and  there  was  less  liquor  amnii  than  usual.  The  placenta  had 
several  succenturiate  lobes.  The  child,  a  male,  was  with  difficulty 
resuscitated,  but  lived  thereafter  for  twelve  days  in  an  apparently 
healthy  condition,  although  it  was  noted  that  the  abdomen  was  un- 
usually large.  After  the  twelfth  day  he  began  to  be  ill  (vomiting, 
crying,  difficulty  in  passing  water),  and  died  on  the  sixteenth  day. 
The  kidneys  were  of  normal  si/e,  liut  in  Ijoth  the  capsules  could 
only  be  stripped  off  with  dilficulty ;  their  substance  was  dense,  and 
the  pelves  not  dilated.  In  size  and  appeai-ance  the  left  ureter  re- 
sembled the  large  intestine  rather  than  a  ureter.  It  showed  a  series 
of  dilatations  which  were  larger  near  its  vesical  end  ;  its  walls  were 
much  thickened,  and  on  one  side  were  longitudinal  bands.  On 
opening  the  ureter,  it  was  seen  that  the  mucous  membrane  was 
arranged  in  folds  at  the  points  corresponding  to  the  external  con- 
strictions ;  in  this  way  great  narrowing  of  the  lumen  was  produced. 
The  right  ureter  presented  similar  l>ut  less  marked  changes.  The 
bladder  was  enlarged  and  its  walls  hypertrophied.  In  yet  another 
specimen,  which  is  in  the  possession  of  Dr.  David  Waterston  (who 


382  ANI'l'.NAr.M.    I'.VIIIOI.OC^-    AND    inClKNK 

is  also  investigating  anew  the  two  previous  specimens),  the  Madder 
walls  were  so  enormously  thickened  as  to  cause  that  viscus  to  sinmlate 
closely  the  uterus,  while  the  kidney  substance  was  reduced  to  nearly 
nothing;  there  was  no  occlusion  of  the  urethra. 

I  have  already  referreil  to  cases  of  fa'tal  ascites  complicated 
with  distension  of  the  bladder  (p.  358),  and  it  will  be  remembered 
tliat  in  one  of  these  there  was  a  meinl)ranous  obstruction  in  the 
urethra  near  the  root  of  the  penis  (107).  It  may  therefore  be  sup- 
posed that  both  in  the  cases  with  ascites  and  thf)se  witlmut  it  there 
was  distension  and  hy]ievtro]ihy  of  the  liladder  (willi  dilatatiim  of 
the  ureters  and  conimencing  liydronephrosis),  on  account  of  the  block 
in  the  urethra  preventing  tiie  e.xit  of  urine  from  tlie  bladder.  There 
are,  however,  recorded  instances  in  wiiich  no olistructioft  (membranous 
or  valvular)  was  found  in  the  urethra,  and  yet  the  bladder  showed 
dilatation  and  hypertrojihy  (tv/.,  the  cases  of  Lefour,  Proi/ris  mM., 
2  s.,  V.  413,  1887,  and  ()  Saintu,  Joxrn.  do  mi'J.  dc  I'ar.,  2  s.,  viii. 
332,  1896,  and  otliers).  In  (1  Mabel  ISlackwood's  case  {loc.  cit.),  also, 
there  was  permeability  of  the  urethra.  Another  very  striking  in- 
stance was  that  reported  by  Couvelaire  {Bull.  Soc.  anat.  dc  far., 
6  s.,  ii.  287, 1900).  The  mother  was  a  1-para,  aged  24  years,  who  had 
some  albuminuria  when  laliour  sujiervened  ])etween  the  eighth  and 
ninth  months.  Parturition  was  delayed,  and  even  after  the  head 
had  been  born  the  trunk  could  not  be  extracted ;  during  attempts  at 
extraction  one  arm  was  fractured,  and  the  infant  succumlied;  it  was 
only  when  the  abdomen  had  been  tapped  and  550  grms.  of  iluid 
(clear,  lemon  yellow,  iiighly  albuminous)  had  been  drawn  oil'  tliat 
the  fo'tus  could  be  fully  born.  The  placenta,  meml)raneR,  and  cord 
showed  no  anomaly.  The  infant,  a  female,  measured  48  cms.  in 
length,  and  weighed  (without  the  fluid)  2900  grms.  The  fluid  had 
come  from  the  peritoneal  cavity,  for  on  exploring  the  abdomen  the 
tensely  filled  and  glo1)ular  bladder  was  discovered  reaching  to  the 
umbilicus.  Its  walls  were  very  thick,  and  the  mtu-ous  membrane 
congested.  The  urethral  canal  was  normal  at  botli  ends,  and  a  stylet 
passed  through  it  easily  ;  there  was  no  block  nor  valve  in  any  part 
of  the  urethra.  The  ureters  were  slightly  dilated ;  the  kidneys  were 
a  little  larger  than  usual,  and  showed  dilatation  of  the  pelves  and 
calyces,  the  renal  tissue  being  reduced  to  a  strip  nowliere  more  than 
4  mm.  thick.  In  cases  such  as  these,  we  are  forced  to  seek  some 
other  explanation  of  the  state  of  the  bladder  and  ureters  than  is 
found  in  the  presence  of  a  block  or  valve  in  tlie  urethra.  Jolm 
Tliomson  has  suggested  (ridi-  C.  I\I.  Blackwood's  i>aper)  that  a  dis- 
turbed nervous  mechanism  may  require  to  be  invoked.  Certainly 
this  explanation  l)ecomes  more  feasible  in  view  of  the  discoveries 
that  have  been  made  regarding  congenital  hypertrophic  stenosis  of 
the  pylorus.  For  some  reason  the  contractile  force  of  the  l)laddcr 
meets  with  resistance  from  the  sphincteric  fibres,  and  as  a  conse- 
(pience  of  prolonged  antagonism  (lasting,  perliajis,  during  a  consider- 
able part  of  fu'tal  life)  hypertro]ihy  of  both  sets  of  muscles  takes 
place.  It  is,  of  comse,  taken  for  granted  that  some  urine  is  l)eing 
secreted  by  the  ftetal  kidneys,  and  doubtless  some  is  expelled  from 


CYSTIC    KIDNEYS  383 

the  bladder  now  aud  again ;  it  seems  necessary  to  sujipose  this  in 
tirder  to  account  for  tlie  great  hypertrophy  of  the  bladiler  walls 
sometimes  met  with.  At  the  same  time,  it  must  be  admitted  tluit  in 
some  of  the  cases  in  which  the  urethra  is  altogetlier  absent,  and  in 
which  there  is  no  exit  for  the  urine  at  all,  the  vesical  walls  still 
exhibit  the  greatest  thickening  (('.^.,in  a  specimen  described  by  Opitz, 
Zlsckr.  f.  Gcburtsh.  u.  Gynak.,  xl.  316,  1899). 

The  chances  of  survival  in  postnatal  life  in  such  cases  as  have 
been  described  above  are  not  necessarily  nil.  It  is  (piite  pro))able  that 
certain  instances  recover.  Unfortunately  it  is  also  more  than  probable 
that  some  cases  in  which  the  obstruction  to  urination  is  slight 
become  worse  after  birth,  on  account  of  the  greater  activity  of  the 
kidneys  then  prevailing;  the  ureters  become  nuich  dilated;  and 
hydronephrosis  more  and  more  marked,  until  death  supervenes.  A 
case  which  was  in  all  probability  of  this  nature  I  saw  in  consultation 
with  Dr.  W.  Stewart  of  Leith  in  1900.  There  was  difficulty  in  the 
birth  of  the  child,  a  male,  on  account  of  the  large  size  of  the 
abdomen.  A  swelling  was  found  in  the  abdomen  chiefly  on  the  left  side, 
apparently  cystic  in  character.  It  did  not  extend  imder  the  margin 
of  the  ribs.  JMicturition  was  not  impossible,  but  it  was  not  free. 
The  child  died  some  days  later,  aud  no  post-mortem  examination 
was  allowed.  I  formed  the  opinion  tliat  we  had  to  do  with  an  in- 
stance of  dilatation  of  the  left  ureter  and  hydrone])hrosis  ;  but  it  may, 
of  course,  have  Ijeen  a  cystic  kidney  or  a  tumour  of  some  other  organ, 
or  even  an  included  tVetus.  Surgery  may  yet  devise  effective  means 
of  dealing  with  many  of  these  cases. 

It  is  not  my  intention  to  describe  here  the  various  antenatal 
pathological  states  which  produce  hydronephrosis.  They  are  nearly 
all  of  the  nature  of  malformations  situated  in  the  ureter  (absence, 
imperforation,  stenosis  from  kinks,  valves,  or  compression  by  other 
structures,  abnormal  communication  with  other  organs)  or  in  the 
urethra  (absence,  imperforation,  stenosis).  Hydronephrosis,  therefore, 
is  generally  the  result  of  teratological  states  rather  than  a  true 
disease.  H.  Brinon  (T/idse,  Paris,  1896)  points  out  that  the  presence 
of  a  supernumerary  ureter  may  explain  some  of  the  anomalies  in 
symptomatology  and  prognosis  which  are  met  with  in  connection 
with  congenital  hydronephrosis. 

Cystic  degeneration  of  the  kidneys  is  another  antenatal  morbid 
state  which  may  cause  delay  iii  the  delivery  of  the  infant  thus 
affected  (L.  Burckhardt,  Indiana  Med.  Joiirn.,  xiv.  295,  1896).  The 
condition  has  been  met  with  in  association  with  a  cystic  state  of  the 
liver,  as  in  the  case  shown  by  Porak  and  Couvelaire  at  the  meeting 
of  the  Socidtd  d'ohstdtriquc,  de  gyni'cologic,  et  dc  2}<'diatrie  of  Paris  in 
January  1901 ;  it  has  also  been  found  combined  with  hydrocephalus, 
as  in  Fin  Holmsen's  case  {Norsk  Mag.  f.  Lmgevidensk.,  Ixi.  411,  1900), 
and  witli  other  anomalies.  It  may  be  due  to  sclerosis  affecting  the 
uriniferous  tubules  specially  in  the  neighbourhood  of  the  papilla^ 
("  papillitis  "),  and  so  causing  retention  of  urine  in  the  kidneys  ;  but 
recent  researches  rather  go  to  show  that  it  is  of  the  nature  of  an 


I 


384  WIIAATAl,    I'AIIIOI.OC.V    AM)    li^CilKNK 

adenomatous  degeneiatinii.  II  the  lutliT  lie  tlie  correct  view,  the 
condition  must  he  rajjardcd  as  a  iii'ii])1;ibiii.  In  M.  }f.  Fussell's  case 
{Mtd.  News,  Iviii.  40,  181)1)  tlic  heai't  was  mucli  liyiierlrophied  ;  it  was 
about  three  times  tlie  normal  size,  and  felt  lil<e  a  soliil  mass  of  fiesli ; 
the  ventricles  were  small  in  size  ;  and  the  valves  were  normal.  What 
bearing,  if  any,  the  cardiac  condition  had  upon  tlie  renal  is  not  clear. 

Diseases  of  the  Genital  Organs. 

It  is  ehirlly  mi  nccniiiil  nf  tlii.  lad  tli.it  iho  rull  dfvclii]iiiient  of 
tlie  genital  nrgans  ilncs  iml  lake  jilacc  till  al'lcr  liirl  h,  that  diseases 
of  these  parts  are  nut  met  with  in  the  I'lclus.  'J'lu'  genitals  are  in  an 
embryonic  state  during  nearly  the  whdle  of  ftetal  life;  they  all'ord  a 
very  clear  illustration  of  the  projection  of  the  endiryonic  into  the 
f(Etal  jieriod.  The  morbiil  states,  therefore,  which  are  met  with  in 
them  at  the  time  nf  jiirlh  are  malformations  and  not  diseases.  In 
regard  to  the  female  organs,  it  is  true,  it  is  stated  that  vaginal  sejiUi 
are  regarded  as  due  to  adhesive  vaginitis  occurring  in  fo'tal  life;  but 
there  is  reason  to  doubt  the  accuracy  of  this  exjilanatinn,  and  to 
look  upon  the  stenosis  as  jiroduced  by  incomplete  canalisation  of 
the  vaginal  anlngc.  Among  the  transnutted  diseases,  syphilis,  it  is 
believed,  affects  the  testicles  and  produces  a  congenital  syjihilitic 
orchitis;  it  may  have  a  similar  effect  on  the  o\aries.  Itut,  with 
these  exceptions,  if,  indeed,  they  be  exceptions,  diseases  of  the  genital 
organs  are  very  rare  in  antenatal  life;  this  is  what  the  principles  of 
Antenatal  Pathology  would  lead  us  to  expect.  There  is,  however, 
one  morbid  coudition,  at  least,  which  may  perhaps  l)e  called  a  disease, 
which  is  occasionally  met  with,  and  about  wdiich  some  words  of  de- 
scription may  here  be  given.     1  refer  to  congenital  prolapsus  uteri. 

Congenital  Prolapsus  Uteri. 

Congenital  prolapse  of  the  uterus  has  been  verj'  seldom  rejiorted ; 
but  it  probably  occurs  more  frequently  than  the  list  of  published  ca.ses 
would  seem  to  show;  for  since  1897,  when  John  Thomson  and  I 
recorded  our  two  cases  (2:}),  the  number  of  observations  has  nearly 
doubled.  Our  attention  was  drawn  to  our  first  case  by  Dr.  Alexander 
Macdonald  of  P]dinburgh,  and  to  our  second  by  Dr.  C.  M'Vicar  of 
Dundee.     The  notes  of  the  former  nf  these  were  as  follows: — 

The  jiatient,  a  girl,  was  six  days  old  when  lirst  seen  by  Thomson 
and  myself.  She  was  the  ynuiigest  of  five  children,  and  the  others 
were  healthy  and  strong.  During  jiregiiancy  the  mother  had  sulfered 
from  no  accident  or  injury.  The  child  was  born  at  full  term  on 
I'ecember  15,  189G,  and,  with  the  exception  of  the  sjiina  bifida  and 
double  club-foot,  ajipeared  healthy.  The  urine  was  jiassed  ireely  and 
the  bowels  were  regular,  although  the  digesiinn  seemed  very  feeble. 
On  Decendjer  17,  the  spina  bilida  liurst,  and  nn  the  next  day  (third 
day  of  life)  prolapse  of  the  uterus  was  seen  for  the  first  time ;  it 
seemed  to  cause  continual  jiain  and  straining.  After  it  appeared  it 
remained  constantly  down.     On  December  21,  we  saw  the  child  for 


w 


CONGENITAL  PROLAPSUS  UTERI         385 

the  tirst  time,  when  we  found  tlie  following  noteworthy  conditions 
(vide  Plate  XIIl.)  :— 

(1)  In  tlie  lumliar  region  there  was  a  large  spina  bifida,  which  had 
burst;  its  base  measured  about  Ih  inch  in  diameter.  (2)  Protruding 
for  about  l  incli  from  the  vulva  was  a  red  mass  closely  resemliling 
prolapsed  bowel.  This,  on  closer  examination,  was  found  to  be 
hypertrophied  cervix  uteri  and  the  adjacent  part  of  the  vaginal  wall. 
A  quantity  of  clear,  gelatinous  secretion  exuded  from  the  os  uteri. 
A  sound  was  passed  within  the  os  and  entered  easily  for  1|  inch ;  it 
could  also  be  passed  into  the  vagina  at  the  side  of  the  prolapse  for 
about  one  incli  all  round.  The  prolapse  went  back  readily  on  slight 
pressure,  but  came  down  again  very  soon  unless  the  surrounding 
parts  were  held  together.  (3)  The  anus  projected  unusually,  and  its 
orifice  was  somewhat  patent ;  a  finger  passed  within  it  was  not 
grasped  at  all.  (4)  There  was  extreme  talipes  varus  on  both  sides. 
The  patella  was  absent  on  the  right  side,  but  present  on  the  left.  No 
abnormality  of  the  head  or  of  the  thoracic  aiid  abdominal  organs  was 
found,  but  the  infant  was  evidently  very  weak.  The  prolapse  was 
returned  and  the  buttocks  kept  in  close  apposition  by  means  of 
plaster  and  a  pad  of  cotton-wool.  The  child  seemed  in  less  pain 
after  this,  but  she  got  gradually  weaker  and  died  the  next  day 
(seventh  day  of  life). 

At  the  post-mortem  examination,  the  heart,  lungs,  liver,  spleen, 
kidneys,  stomach,  and  intestines  were  found  to  be  normal.  The 
pelvis  and  the  lower  part  of  the  spine  were  removed  for  further 
investigation ;  they  were  placed  in  a  freezing  mixture,  the  prolapse 
having  been  previously  reproduced.  A  vertical  mesial  section  was 
then  made,  and  the  appearances  of  the  right  slab  are  shown  in  Plate 
XIIL  The  appearances  may  be  usefully  contrasted  with  those  seen 
in  Fig.  22  (p.  118).  There  could  be  no  doubt  the  uterus  wa.S  really 
prolapsed,  for  its  fundus  lay  at  the  level  of  the  coccyx  instead  of 
well  above  the  pelvic  brim.  The  cervix  distended  the  vulva,  and 
protruded  slightly  from  it :  but  the  degree  of  protrusion  was  much 
less  than  during  life.  The  direction  of  the  uterine  axis  contrastetl 
markedl)'  with  that  in  the  normal  state.  The  bladder,  whose  cavity 
on  section  had  a  Y-shape,  was  situated  lower  in  the  pelvis  than  usual ; 
and  there  was  also  a  certain  degree  of  prolapse  of  the  vaginal  walls. 
The  rest  of  tlie  pelvis  was  occupied  by  the  rectum  and  the  intestinal 
coils.  The  sacrum  showed  no  indication  of  a  promontory,  and  the 
lower  part  of  the  spinal  column  was  perfectly  straight  save  for  a  slight 
bending  back  of  the  tip  of  the  coccyx.  The  defect  in  the  posterior 
wall  of  the  spinal  canal  affected  the  last  lumbar  and  the  first  two  or 
three  sacral  vertebrie,  and  the  cauda  equina  was  seen  spread  out  over 
the  inner  surface  of  the  spida  bifida  sac.  A  distinct  perineal  body  of 
a  triangular  shape  existed,  the  vaginal  rugie  were  well  marked,  and 
the  distended  vulvar  orifice  showed  an  unruptured  annular  hymen. 
Dissection  of  the  pelvic  contents  revealed  the  ovaries  and  Fallopian 
tubes  lying  slightly  aliove  the  level  of  the  fundus  uteri  at  the  sides  of 
the  pelvic  cavity.  The  Ijroad  and  round  ligaments  were  greatly 
stretched  and  thinned.  The  connective  tissue  in  the  pelvis  seemed 
25 


386  ANTENATAL    I'AI'l  1()I.()(;Y    AND    HYCIF.NK 

to  be  smaller  in  ainount.  than  normal,  Imt  tlie  infant  herself  was  not 
at  all  plump.  The  urethra  was  jiatent.  The  diameters  of  the  false 
pelvis  were  below  the  normal,  while  those  of  the  true  ])elvis,  both  at 
the  brim  and  outlet,  were  distinetly  aiiove  the  averajic  The  total 
length  of  the  uterus  was  o-2  cms.,  of  which  2  cms.  lielonged  to  the 
cervix  and  r2  cm.  t(j  the  body.  The  transxerse  diameter  at  the 
fundus  was  lb  cm.,  and  the  antero-posterior  only  O'o  cm.;  the  cervix 
had  an  antero-posterior  measurement  of  1-2  cm.  and  a  transverse 
of  1-0  cm.  Save  for  a  certain  but  not  a  great  degree  of  cervical 
enlargement,  these  uterine  diameters  did  not  ditier  much  from  those 
in  normal  infants.  Tiie  distance  between  the  anal  and  vulvar 
apertures  was  1"0  cm. 

The  second  case  that  Thomson  and  1  reported  was  .somewhat 
similar.  As  in  the  first,  the  jnesentation  at  birth  was  l)y  the  vertex. 
The  spina  bifida  sac  had  burst  during  delivery  in  this  instance. 
There  was  double  talipes  varus,  and  no  patella  could  be  felt  on  either 
.side.  Dr.  M'Vicar  noticed  the  prolapse  of  the  uterus  on  the  day 
following  the  birth  of  the  infant.  There  was  also  slight  eversion  of 
the  rectal  mucous  membrane.  The  child  died  in  five  days.  In  other 
details,  clinical  as  well  as  pathological,  the  two  cases  were  very 
similar. 

Previous  to  the  publication  of  these  two  cases,  there  had  been 
records  of  six  instances  of  congenital  prolapsus  uteri.  These  were 
those  of  Schultz  {Vcrhandl.  d.  Ver.  pfalz.  ^ers^c,  1856,  Kaiserslautern, 
48,  1857),  of  N.  Qvisling  {Norsk  Mag.  f.  Laegcridcnsk.,  4  K.,  iv.  265, 
1889;  Arch.  f.  Kinderh.,  xii.  81,  1890-1),  of  0.  Schaeffer  (Anh.  /. 
Gynach.,  xxxvii.  244,  1890),  of  K.  Heil  (Arch.  f.  GynacL,  xlviii.  155, 
1894),  of  S.  Kemy  (Arch,  dc  tocoL,  xxii.  904,  1895),  and  of  L.  Krause 
(in  Neugebauer's  article  in  the  Gazeta  Irkrirska,  xvi.  1223,  1896). 
Since  then  cases  have  been  published  by  Hausson  (Mvnchen.  mcd. 
Wchnschr.,  xliv.  1040,  1897),  bv  Radwansky  (J/w^f/tr^.  med.Wchnschr., 
xlv.  53,  1898),  by  A.  Doleris  (t'ywAo/or/fV,  iii.  220,  1898).  ami  by  H.  E. 
Andrews  (Trans.  Ohst.  Soc.  Lond.,  xlii.  109,  1900).  From  the  account 
which  has  been  given  of  the  cases  reported  by  Thomson  and  myself, 
and  from  a  consideration  of  the  literature  of  the  subject,  the  following 
conclusions  may  be  arrived  at : — 

There  is  an  evident  and  real  downward  displacement  of  the  uterus 
which  occurs  soon  after  or  at  birth  ;  this  is  not  the  same  as  congenital 
hypertrophic  elongation  of  the  cervix,  although  there  may  be  a  certain 
degree  of  cervical  enlargement  present,  and  in  the  case  of  Dolcris  the 
two  anomalies  were  combined.  The  pregnancy  and  labour  which 
preceded  the  birth  of  an  infant  suflering  from  prolapsus  uteri  seem 
geiun-ally  to  have  lieen  uneventful ;  but  in  the  cases  o*^  Qvisling  (loc. 
cit.)  and  Hansson  (loc.  cit.)  the  presentation  was  by  the  breech.  The 
infant  was  always  l)orn  alive,  but  died,  with  one  exception,  some  days 
later.  In  Krau.se's  subject  (Centrlhl.  f.  Gipiak,  xxi.  422,  1897)  the 
prolapse  was  apparently  ]iresent  at  the  moment  of  birth,  and  may 
have  been  in  existence  in  f(etal  life;  but  in  the  other  cases  the  dis- 
jjlacement  occurred  from  a  few  hours  to  several  days  after  birth.  In 
Schultz's  case  (loc.  cit.)  it  did  not  a)i]iear  for  ten  weeks,  aiul  therefore 


CONGENITAL  PROLAPSUS  UTERI         387 

this  observation  perhaps  ouglit  not  to  be  grouped  with  the  others. 
In  all  the  recorded  instances  the  prolapse  was  easily  replaced,  and  in 
none  had  the  uterine  displacement  anything  to  do  with  the  death  of 
the  child.  The  concomitant  malformations  were  eversion  of  the 
lectal  mucous  meuilirane,  talipes,  spina  liifida,  and  (in  Krause's  case) 
hypertrichosis. 

It  is  a  most  remarkable  fact  that  in  nearly  every  case  there  should 
have  been  concomitant  spina  bifida  of  the  lumbo-sacral  region.  At 
the  time  when  Thomson  and  I  published  our  two  cases,  there  were 
eight  cases  on  record,  and  in  seven  of  these  there  was  the  spinal 
defect,  while  in  the  eighth  it  is  possible  that  it  was  also  present 
although  not  referred  to.  In  Hansson's  observation  there  was  also 
spina  bifida.  It  was  therefore  with  great  interest  that  I  perused 
Andrews'  report  of  a  case  in  which  this  commonly  associated  defect 
was  not  present.  In  this  instance  the  swelling  at  the  vulva  was 
noticed  a  few  hours  after  birth ;  it  bled  when  handled ;  and  it  con- 
sisted of  the  much  swollen  cervix  uteri.  The  anus  admitted  the  tip 
of  the  finger,  but  the  rectum  was  imperforate,  necessitating  inguinal 
colotomy.  The  child  died  on  the  twelfth  day  of  life,  and  before  this 
time  the  uterus  could  be  retained  in  position  without  strapping.  It 
is  noteworthy  that  in  this  case,  although  there  was  no  spina  bifida, 
yet  there  was  another  associated  malformation,  namely,  rectal  im- 
perforation.  In  a  letter  which  I  received  from  Dr.  Andrews,  dated 
May  29,  1900,  it  is  stated  that  the  post-mortem  examination  revealed 
nothing  abnormal  save  the  imperforate  rectum.  In  Eadwansky's 
case  also  {loc.  cit.)  there  seems  to  have  been  neither  spina  bifida  nor 
hydrocephalus ;  in  that  instance  the  prolapse  was  present  at  birth, 
and  the  protruded  mass  measured  4  cms.  in  length ;  there  was  some 
ulceration  of  the  exposed  cervix  uteri ;  great  improvement  followed 
replacement  and  retention ;  and  at  the  end  of  six  months  the  infant 
was  still  living  and  the  prolapsus  was  feebly  marked.  The  cases  of 
Eadwansky  and  Andrews  demonstrate  that  the  association  of  con- 
genital prolapsus  uteri  with  spina  bifida  in  the  lumbo-sacral  region 
cannot  be  looked  upon  as  constant ;  at  the  same  time  this  association 
existed  in  nine  out  of  twelve  cases,  and  must  be  regarded  as  too 
frequent  to  be  a  mere  coincidence.  It  is  no  longer  justifiable  to  say 
that  congenital  prolapsus  uteri  is  always  a  symptom  of  lumbo-sacral 
spina  l)ifida ;  but  it  must  still  be  looked  upon  as  sometimes  such 
a  symptom.  This  leads  me  to  discuss  the  pathogenesis  of  congenital 
uterine  prolapse. 

It  is  natural  that  most  of  the  observers  who  have  had  to  deal 
with  congenital  prolapsus  uteri  have  been  struck  by  the  presence  of 
lumbo-sacral  spina  bifida,  and  have  given  it  a  place  in  their  theories 
of  pathogenesis.  Further,  in  several  of  the  cases  there  was  a  semi- 
paretic  condition  of  the  lower  limits,  a  circumstance  which  seemed  to 
favour  the  idea  of  a  nervous  origin  of  the  prolapse.  Possibly  the 
spina  bifida  causes  defective  innervation  of  the  pelvic  ligaments  and 
viscera,  with  a  general  condition  of  laxity  of  the  tissues ;  the  associa- 
tion of  slight  rectal  prolapse  favours  this  view.  But  it  is  evident 
that  the  whole  causation  of  the   displacement  cannot  be  thus  ex- 


388  ANTKNAJAL    l"AllI()I,()(iY    AM)    IIVCIKNR 

plained,  f(jr  wliilo  spina  liitida  is  comparatively  coiiiinon,  congenital 
prolapse  would  appear  to  he  very  rare.  Other  contrihuting  causal 
factors  may  he  found  in  defective  development  of  the  connective 
tissue  of  the  i)elvis,  in  enlargement  ol  the  pelvic  inlet  and  outlet  hy 
the  straight  character  of  the  himljo-sacral  part  of  tiie  spine,  in 
narrowing  of  the  false  pelvis,  in  enlargement  of  tiie  cervix  (alliiough 
this  is  far  from  constant),  and  in  increased  intra-al)dominal  pressure 
(due  to  down-hearing  and  straining  elVorts  made  liy  the  infant). 

It  is  noteworthy  that  the  condition  is  n(jt  invariahly  fatal,  for 
Eadwansky's  subject  was  alive  at  si.K  months.  In  the  absence  of  the 
spina  bifida  (there  was  none  in  Eadwansky's  case)  there  seems  then 
to  be  the  double  cliance  of  survival  of  the  infant  and  of  cure  of  the 
displacement.  Even  when  the  displacement  is  associated  with  the 
defective  state  of  tlie  spinal  canal,  there  seems  to  be  no  reason  always 
to  anticipate  a  fatal  termination,  for  spina  bifida  is  sometimes  success- 
fully operated  upon. 

In  connection  with  the  above  description  of  congenital  prolapsus, 
I  may  mention  that  I  have  seen  (in  consultation  with  Professor 
Annandale)  a  case  of  congenital  rectal  prolapse  in  a  female  infant, 
two  years  of  age.  There  was  great  defect  of  the  perineum ;  indeed, 
the  infant's  external  genitals  resembled  very  closely  those  of  a  woman 
who  had  had  a  had  laliour,  with  a  nearly  complete  laceration  of  the 
perineum.  There  was,  however,  no  evidence  whatever  of  uterine 
prolapse.  There  was  no  spina  bifida  and  no  other  malformations. 
The  prolapse  of  the  rectal  wall  was  anterior  and  on  tlie  left  side. 

Diseases  of  the  Nervous  System. 

In  attempting  to  describi'  I'ven  very  brietly  the  idiopathic  diseases 
of  the  nervous  system  wliich  are  present  in  fo'tal  life,  one  is  met 
at  the  outset  by  two  very  consideralile  difficulties.  One  of  these  is 
the  interposition  between  antenatal  and  postnatal  life  of  the  short 
traumatic  interval  of  intranatal  life  during  which  the  head  of  the 
infant  and  other  parts  also  are  suftering  from  pressure  in  the  liirtli 
canals.  There  seems  to  lie  little  doubt  tliat  during  this  intercalaiy 
period  many  of  the  so-called  oljstetrical  paralyses  occur,  and  tliat 
they  are  duo  to  intracranial  haemorrhages;  but  it  has  to  be  liorne 
in  mind  also  tliat  intracranial  and  even  intracerebral  effusions  may 
be  the  result  of  fcetal  morbid  states  prior  to  the  advent  of  labour, 
as  has  been  proved  by  Osier's  case  (Trrafolof/ia,  ii.  13,  189")),  to 
which  reference  has  already  been  made  (p.  201).  At  present  we 
know  of  no  certain  metho(l  of  distinguishing  between  and  of  dis- 
entangling the  one  set  of  maladies  from  the  oMier.  The  other 
difficiUty  is  due  to  tlie  fact  that  during  foetal  life  the  nerve  centres 
are  still  in  the  embryonic  stage,  and  that  therefore  the  morbid 
affections  which  may  occur  in  them  are  more  of  the  nature  of  malfor- 
mations than  of  diseases.  That  these  malformations  may  give  rise 
after  birtli,  and  sometimes  long  after  birth,  to  diseases  in  the  ordinary 
acceptation  of  the  word,  is  undoubted  :  lait  then  tiiese  diseases  caiiiint 
accurately  be  described  as  existing  in  tiie  fictus.     Tiiey  are  potentially 


HYDROCEPHALUS  389 

present  in  it,  that  is  all.  To  some  of  these  maladies  the  term 
"  congenital "  is  atlixed,  and  to  some  others  that  of  "  hereditary  " ; 
the  former  expression  has  been  used  very  loosely  to  signify  any 
condition  which  is  either  actually  present  or  only  predisposed  to  at 
the  time  of  birth,  and  the  latter,  if  taken  in  its  correct  sense, 
indicates  that  the  morbid  state  which  develops  after  birth  was 
present  already  in  the  impregnated  ovum  Ijefore  embryogenesis 
commenced  or  ever  fcctal  life  began.  Most  of  the  "  congenital " 
diseases  of  the  nervous  system  are  antenatal  only  in  the  sense  of 
being  potentially  present  at  Ijirth  ;  they  are  the  results  of  malforma- 
tions wliose  effect  becomes  evident  after  birth.  Some  are  doubtless 
"  hereditary "  also,  in  the  sense  that  the  tendency  towards  the 
malformation  of  certain  parts  of  the  nervous  system  is  transmitted 
from  parent  to  child.  From  all  these  facts  it  follows  that  it  is 
practicolly  impossible  to  select  for  description  any  types  of  truly 
fidal  diseases  of  the  nervous  system.  The  most  that  can  lie  done  is 
to  refer  to  certain  morbid  states  of  the  brain  and  cord  in  order  to 
demonstrate  how  impossible  it  is  to  find  any  types.  The  conditions 
to  which  I  allude  might  perhaps  be  called  "  teratological  diseases  " 
potentially  present  before  birth ;  but  the  ex^jression  is  rather  of  the 
nature  of  a  contradiction  in  terms. 

For  instance,  there  is  congenital  internal  hijdrocephalus.  Are  we  to 
regard  the  distension  of  the  cerebral  ventricles  in  this  morbid  state 
as  a  fu'tal  disease,  as  an  embryonic  malformation,  or  as  a  disease 
due  to  a  precedent  malformation  ?  Is  it  due  to  an  intlanlmatoiy 
change  in  the  lining  membrane  of  the  cerebral  ventricles  and  of 
the  central  canal  of  the  spinal  cord,  to  an  inflammation  of  the 
ependyma  ?  Is  it,  on  the  other  hand,  purely  a  malformation  of  the 
lirain  ?  Is  it  primarily  a  malformation  which  predisposes  to  inflam- 
matory or  (jther  pathological  changes  which  induce  effusion  of  fluid 
into  the  ventricles  ?  The  pathologist  who  would  venture  to  answer 
any  of  these  queries  definitely  might  be  bold,  but  it  is  doubtful 
if  he  could  claim  justification  for  his  boldness.  Personally  I  incline 
to  the  third  view.  The  fact  that  the  parents  of  hydrocephalic  infants 
not  infrequently  are  syphilitic  or  alcoholic,  does  not  greatly  clear 
up  this  question,  although  otherwise  it  is  a  fact  of  very  considerable 
importance ;  for,  as  we  have  seen  (pp.  239,  276),  both  syphilis  and 
alcoholism  in  the  parents  may  be  revealed  in  the  progeny  either 
l:)y  disease  or  malformation.  Neither  does  the  fact  of  the  frequent 
coexistence  of  various  malformations  in  cases  of  hydrocephalus 
prove  that  the  latter  is  a  malformation,  although  this  fact  also  is 
interesting.  Hydrocephalus,  therefore,  must  be  left  as  an  indefinite 
morbid  state  of  the  ftetus,  likely  to  produce  delay  in  labour  and 
danger  even  to  the  mother,  but  with  a  pathology  and  pathogenesis  as 
yet  unexplained.  The  careful  investigation  of  early  stages  in  the 
evolution  of  the  morbid  state  wovdd  most  probaldy  yield  results  of 
great  value ;  the  pathologist  ought  to  lie  on  the  outlook  for  slight 
hydrocephalus  in  cases  in  which  there  may  be  spina  bifida,  but  in 
which  there  is  as  yet  no  cranial  enlargement. 

Again,  there  is  Little's  disease,  or  congenital  spastic  rigidity,  or 


390  ANTENATAL    I'ATHOI.OdY    AND    HYGIENE 

congenital  cerebral  paralysis.  In  this  malaily  the  iiiiaiit  shows 
contraclures  of  various  muscles,  with  ]iaia]Fh'i,'ia  or  iiioiiojilej^na.  The 
child  begins  to  walk  late,  and  develii]is  tiie  jiceuliar  sjiastie  pdl  with 
niai'ked  cross-legged  progression.  Tlic  dee])  retle.xes  are  exaggerated, 
and  squinting  is  common.  There  is  usually  a  great  deal  of  mental 
disturl>ance,  amounting  sometimes  to  indiecility  and  idiocy.  The 
name  "  congenital  "  is  generally  applied  to  tliese  cases;  but  tliere  is 
good  reason  to  believe  that  most  of  tliem  are  due  to  tlie  traumatism 
of  birtli  (pelvic  (ir  foreejjs  pressure  on  tlie  liead),  causing  meningeal 
luemorrhage,  followed  by  sclerosis  and  ))iirence]>haly.  At  the  same 
time  there  are  some  instances  which  are  hardly  to  be  explained 
in  this  way,  and  whicli,  therefore,  suggest  a  truly  antenatiil  as  well 
as  an  intranatal  factor  in  the  pathogenesis  of  the  cerebral  paralysis ; 
but  the  condition,  like  hydrocephalus,  although  for  another  reason, 
cannot  be  regarded  as  a  typical  ftetal  disease  of  the  nervous  system. 

Congenital  chorea  is  another  so-called  congenital  malady  of  the 
nervous  system.  In  some  instances  the  choreic  movements  have  been 
noticed  at  birth.  There  is  an  absence  of  rigidity,  although  some  writers 
would  apply  the  name  "  congenital  chorea  "  to  the  cases  in  which  there 
is  concomitant  spastic  rigidity.  The  pregnancy  has  generally  been 
abnormal;  the  mother  may  have  suffered  from  injuries,  from  friglits, 
from  prolonged  or  instrumental  labour,  or  from  some  disease;  and  in  a 
few  remarkable  cases  the  mother  as  well  as  her  infant  has  liad  chorea. 
There  may  be  a  family  history  of  alcoholism  or  epilepsy.  Birth  is 
often  premature.  The  infant  may  be  diflicult  to  resuscitate  at  Itirtli, 
but  if  successfidly  treated  shows  even  within  a  few  hours  marked 
choreic  movements  and  grimaces,  wjiich  cease  during  sleep.  He  is  late 
in  walking,  but  ultimately  walks  well  save  for  a  slight  unsteadiness ; 
in  this  respect  the  malady  contrasts  strongly  with  Little's  disease. 
He  is  backward  in  his  mental  development.  Here  then  is  a  disease 
which  may  perhaps  lie  taken  as  a  type  of  the  maladies  of  the  nervous 
sj'stem  which  are  produced  during  fci'tallife;  but  when  the  etiology 
and  pathogenesis  come  to  be  inquired  into,  its  typical  cliaracter  soon 
disappears.  Yignaud  Dupuy  de  St.-Florent  {These,  V:\v\&,  lS9;"i)  lias 
summarised  our  knowledge  on  these  points.  It  would  a]»pear  that 
congenital  chorea  may  be  transmitted  directly  from  mother  to  fo'tus; 
in  one  case,  that  of  Eieder  {Miinchen.  med.  IFchnxchr.,  xx.wi.  60.S,  1SS9), 
the  transmission  was  from  grandmother  to  mother,  and  then  from 
mother  to  daughter.  This  may  be  explained  either  as  a  transmi.ssion  of 
the  morbid  state  directly  to  the  fo'tus  in  utero,  or  as  a  hereditary 
handing  down  tlu'ough  tlie  germ  ])rior  to  impregnation.  If  the 
former  view  be  accepted,  the  exi)lanation  of  the  pathogenesis  1)ecomes 
practically  impossible  tlirough  lack  of  facts:  if  the  latter  view  be 
maintained,  it  may  be  argued  that  lu-re  we  lia\r  to  do  willi  a 
conejeniteil  form  of  Huntingdon's  chorea  whirh  is  cNidciitly  here- 
ditary. It  seems,  however,  to  dilVer  in  .several  iiarliculars  from  the 
markedly  hereditary  instances  of  tremor  (some  of  them  being  con- 
genital) which  were  described  by  C.  L.  Dana  (Internal.  Jonrii.  Med. 
Sc.,  xciv.  386,  1887).  Trobably,  or  possibly,  the  three  conditions 
(Huntingdon's  chorea,  congenital  chorea,  ami  hereditary  tremor)  are 


HEREDITARY    ATAXIA  391 

all  essentially  differeut.  At  any  rate,  they  do  not  throw  much  light 
upon  each  other,  even  although  they  agree  in  being  transmitted  from 
ascendants  to  descendants.  St.-Florent  (op.  cit.)  looks  for  an  anatom- 
ical or  functional  anomaly  of  development  of  the  fretal  brain  to 
explain  congenital  chorea ;  in  other  words,  he  regards  it  as  a  disease 
due  to  a  teratological  state,  but  includes  under  the  latter  term  tlie 
idea  of  a.  functional  malformation ,  so  to  say.  He  also,  however,  seems 
to  look  to  traumatism  in  labour  as  the  primary  cause  of  the  cerebral 
malformation.  It  is,  therefore,  abundantly  evident  that  congenital 
chorea,  no  more  than  Little's  disease  or  hydrocephalus,  can  be  taken 
as  a  type  of  the  tretal  diseases  of  the  nervous  system. 

Friedreich's  ataxia  has  sometimes  been  termed  "  congenital 
ataxia "  and  "  family  ataxia,"  but  "  hereditary  ataxia "  is  a  name 
which  better  indicates  its  nature;  fur  it  is  never  observed  in  the  first 
nicmths  of  life,  and  it  is  not  a  constant  occurrence  that  it  affects 
several  members  of  the  same  family.  Even  if  the  term  "  hereditary  " 
be  adopted,  it  must  be  borne  in  mind  that  it  is  rare  for  the  heredity 
to  be  direct  and  similar.  Further,  it  is  a  slowly  developed  disease ; 
there  is  nystagmus,  loss  of  muscular  power,  and  sometimes  of 
the  patellar  reflex,  speech  disturbance,  and  mental  impairment ; 
all  these  changes  appear  in  late  childhood,  and  are  established  slowly. 
It  is  due  to  a  chronic  inflammatory  (?)  degeneration  of  certain  parts 
of  the  spinal  cord  (posterior  columns,  lateral  and  cerebellar  tracts, 
columns  of  Clarke,  etc.) ;  and  it  has  been  thought  that  this  degenera- 
tion has  been  predisposed  to  by  an  arrest  of  development  of  the  cord 
in  fo'tal  life.  In  it,  also,  is  seen  the  association  of  a  disease  with 
a  malformation  ;  perhaps  we  may  call  it  a  "  teratological  disease,"  if 
we  keep  in  mind  that  such  an  expression  is  in  large  measure  an 
inilication  of  ignorance. 

Of  Thomsen's  disease,  or  myotonia  congenita,  or  muscular  ataxia,  I 
need  say  little.  It  is  often  transmitted  from  ascendants  to  descend- 
ants :  it  begins  in  early  childhood ;  and  it  is  characterised  by  the 
fact  that  during  voluntary  movements  the  muscles  respond  slowly  to 
the  will,  being  late  in  contracting  and  slow  in  relaxing  again.  It 
has  been  regarded  as  a  "  congenital  "  affection  of  the  muscular  fibres, 
a  primary  myopathy  ;  it  has  also  been  looked  upon  as  representing  a 
congenital  antagonism  between  the  muscular  and  nervous  systems 
with  ultimate  predominance  of  the  former.  Clearly,  however,  it  also 
falls  into  this  group  of  mysterious  pathological  states,  the  so-called 
foetal  diseases  of  the  nervous  system. 

The  same  characters  of  indefiniteness  and  of  confusion  between 
malformations  and  diseases  extend  to  the  antenatal  morbid  states 
of  the  organs  of  special  sense.  An  instance  of  this  is  met  with  in 
the  condition  known  as  "congenital  clouding  of  the  cornea"  which  may 
be  due  to  "  an  arrest  in  development  "  or  to  an  "  intrauterine  inflam- 
mation." It  has  been  ascribed  to  syphilis,  but  has  been  met  with 
in  the  lower  animals,  and  cannot,  therefore,  always  be  syphilitic  even  if 
it  occasionally  be  so. 

I  offer  no  apology  for  the  vagueness  of  the  descriptions  of  the 
nervous  diseases  of  the  foetus.     It  was  late  in  the  history  of  medicine 


392  ANll.NAlAl,    l'A■m()l.()(;^     AM)    1 1 VCI  I'.NJ-: 

before  tlie  adult  maladies  of  the  nervous  system  began  to  be  under- 
stood ;  even  now  they  constitute  a  most  difhcult  part  of  medicine. 
It  is  not  to  be  expected  that  the  part  of  Antenatal  Pathology 
which  deals  with  the  morbid  changes  in  the  l)rain,  spinal  ctu-d, 
and  organs  of  special  sense,  will  be  less  ditlicult  or  less  late  in  being 
elucidated.  Two  matters  have  led  to  great  obscurity  :  the  inter- 
relation of  the  malformations  and  tlic  di.scases  of  the  fo'tal  nervous 
system,  and  the  intrusion  into  the  subject  of  the  iilea  of  antenatal 
functional  disorders.  But  these  comi)licatiiins  and  (tbscurations  must, 
I  think,  be  accepted  as  inevitable.  To  luiuimise  the  difliculties  is 
to  retard  real  progress;  short  cuts  to  conclusions  are,  in  Antenatal 
Pathology  at  least,  too  often  nothing  but  bliuil  alleys ;  the  way  has 
to  be  retraced,  and  valuable  time  has  l)eeii  lost.  It  must  lie  slowh' 
that  progress  is  accomplished;  it  must  be  by  careful  observing  and 
accurate  reporting  of  cases,  with  full  details  of  the  jihenomena  of  tlie 
first  weeks  and  nuniths  of  life  and  of  the  events  of  pregnancy:  ami 
complete  post-mortem  examinations  will  have  a  paramount  import- 
ance. Since  many  of  the  maladies  are  hei-editary,  and  sliow  family 
prevalence,  we  may  yet  learn  much  from  the  post-mortem  examination 
of  still-born  infants,  or  of  relatives  who  have  died  without  necessarily 
showing  any  symptoms  of  the  particular  disease,  for  in  them  the 
predisposing  malformations  which  are  of  so  much  imthogenetic 
importance  may  perchance  be  found.  Manifesth'  the  matter  is  beset 
with  dittieulties ;  therein  lies  our  stinmlus  to  work:  other  matters 
have  been  no  less  dillicult,  but  have  become  the  commonplaces  of  tlie 
text-book ;  herein  exists  our  encouragement. 

With  the  end  of  this  chapter  I  close  the  X'ai't  of  this  work  which 
deals  with  the  idiopathic  diseases  of  the  fcetus.  It  is  an  unsatisfactory 
part ;  for  all  the  while  that  we  are  considering  these  maladies  we  are 
wondering  whether  they  really  are  idiopathic,  whether  indeed  they 
are  not  transmitted  from  ])arent  to  child,  if  not  in  the  foetal  jieriod  of 
life  at  any  rate  in  the  germinal.  No  doulit  some  of  them  will  yet  lie 
transferred  to  the  group  of  the  transmitted  maladies.  At  the  same 
time  it  is  a  most  suggestive  part  of  the  work,  for  it  has  introduced  to 
us  the  idea  of  functional  antenatal  maladies  in  connection  with 
hypertrophic  stenosis  of  the  pylorus,  and  with  some  of  the  morliid 
states  of  the  nervous  system.  Further,  it  has  illustrated  the  interest- 
ing albeit  most  diflicult  question  of  the  inter-relation  of  malformations 
and  diseases,  and  of  the  projection  of  the  embryonic  into  the  fcetal 
period  of  antenatal  life,  with  all  the  con.sequences  which  How  there- 
from. About  many  of  the  questions  which  have  arisen  in  the  ] ac- 
ceding chapters,  I  have  been  forced  to  give  judgment  in  tlie 
unsatisfactory  form  of  no7i  liquet ;  but  although  "  it  is  not  clear  "  now 
and  to  me,  yet  there  may  be  illumination  soon  and  for  another.  To 
have  put  down  the  ditlicvdties  and  the  scanty  facts  in  black  and  white 
is  something,  and  marks  at  any  rate  a  stage,  or  at  least  a  new 
starting  point.      Vox  cmixsa  rolaf — lifera  scri}}ta  manct. 


CHAPTER  XXIII 

Traumatic  Jlorbid  States  of  tlie  Ftetus  :  Fa'tal  Fractures,  AVounds,  and  Dis- 
locations; Congenital  Aminitations ;  Diseases  of  the  Ftetal  Annexa ; 
Placental  H;eniorrliages  ;  Fibro-Fatty  Degeneration  of  the  Placenta  ;  Slorljid 
States  of  the  Umbilical  Cord  ;  Hydramuios — Definition,  Clinical  History, 
Symptomatology,  Physical  Signs,  Diagnosis,  Prognosis,  Pathology,  Patho- 
genesis, Treatment  ;  Oligohydramnion. 

In  the  classification  of  foetal  morbid  conditions  given  on  page  175, 
I  gave  i^laces  to  neoplasms  and  traumatic  morbid  states;  ))ut  I 
indicated  that  it  would  probably  be  necessary  to  exclude  the  former, 
as  their  origin  in  the  foetal  period  was  more  than  questionable.  The 
tumours,  like  the  monstrosities  and  most  of  the  malformations,  are, 
so  to  say,  handed  on  into  the  fietal  period  from  the  embryonic  and 
germinal  epochs  of  antenatal  life  ;  the  ftetus,  as  it  were,  carries  them 
with  it  through  the  rest  of  intrauterine  existence  into  the  light  of 
day,  and  they  are  then  recognised  for  the  first  time,  but  their  origin 
lies  far  away  back  in  embryonic  or  germinal  life.  The  more  one 
studies  the  so-called  traumatic  morbid  states  of  the  fa^tus,  the  more 
one  is  forced  to  l^elieve  that  they  also  anticipate  the  truly  ftftal 
period.  If  we  exclude  the  fractures  and  dislocations,  and  wounds 
and  lacerations  and  avulsions,  which  occur  at  the  time  of  birth  in 
consequence  of  grave  disproportion  lietween  the  size  of  the  maternal 
pelvis  and  that  of  the  fcetus  passing  through  it,  we  are  left  witli  a 
group  of  enigmatical  morl)id  states  which,  on  a  superficial  examination, 
suggest  the  idea  of  intrauterine  injuries  of  various  kinds.  A  more 
careful  examination  of  these  conditions  (fractures,  dislocations, 
wounds,  and  amputations),  however,  at  once  raises  doubts  as  to  their 
traumatic  character,  if,  at  least,  "  traumatic "  be  tinderstood  in  its 
ordinary  sense.     Let  us  consider  some  of  these  morl)id  states. 

Foetal  Fractures. 

By  "  fcetal  fractures,"  we  mean  not  so  much  the  fractures  met 
with  at  Ijirth  which  have  evidently  been  recently  produced,  and  to 
explain  which  some  manifest  traumatism  has  occurred  during  the 
course  of  tlie  confinement ;  the  name  is  or  ought  to  be  reserved  rather 
for  the  morbid  states  which  have  Ijeeu  regarded  as  badly  united  or 
ununited  fractures.  When  one  meets  with  a  bone,  such  as  the  femur 
or  clavicle,  which  shows  an  irregular  swelling  or  a  sharp  Ijend  of  its 
shaft,  or  which  exhibits  a  fracture  with  two  rotmded  fragments  lying 
close  together  but  not  united,  it  has  often  Ijeen  maintained  that  here 
was  an  instance  of  a  fracture  which  had  been  produced  during  foetal 


394  ANTKNATAI.    I'A  rilOI.OCV    AM)    IIVdlENE 

life  by  external  violence  or  hy  strong  uterine  contraetious.  '11  ic 
separate  fragnientis  liad  not  lieen  l)rou<;ht  into  exact  apposition,  ;\iu\ 
consequently  liad  united  at  an  angle,  or  nnieh  callus  had  been  tlirown 
out,  producing  the  nodular  swelling  on  the  shaft :  or,  in  some  instances, 
the  two  segments  had  been  too  far  apart  or  had  been  so  mobile  that 
no  union  at  all  had  occurred,  and  in  time  tiie  ends  had  become  rounded 
and  a  kind  of  false  joint  had  l)een  produced.  When  there  was  no 
history  of  traumatism  during  hiliour,  or  of  excessive  muscular  action, 
the  supporters  of  the  above  tlieory  of  caii.satioii  were  compelled  to 
suppose  that  the  fietal  skeleton  had  been  unusually  brittle,  or  that  it 
had  at  one  period  of  to'tal  life  passed  through  a  stage  of  abnormal 
fragility.  There  is  reasim  to  believe  that  in  some  exceptional 
instances  such  a  chain  of  causal  factors  has  really  existed,  as,  for 
exam])le,  in  the  case  reported  by  Paul  Linck  {Arcli.  f.  Gynacl:,  xxx. 
2G4,  1887),  in  which  the  expulsion  of  tlie  infant  took  place  in  little 
more  than  one  pain,  and  in  which  there  were  over  thiity  fractures 
(old  and  recent)  in  the  limbs,  sternum,  ribs,  etc. ;  or  in  those  put  on 
record  l)y  Chaussier  {Bull.  Fac.  dc  vied,  de  Par.  (1812-13),  iii.  301, 
1814),  in  which  lalxnir  was  easy,  and  yet  from  fifty  to  a  hundred 
fractures  were  counted  after  birth.  The  exceptional  brittleness  of  the 
bones  has  in  these  cases  been  attriliuted  to  true  rickets,  to  "  fo'tal 
rickets,"  and  to  an  "  ind<uown  intrauterine  disease  of  the  fecial 
skeleton"  (Linck).  In  the  great  majority  of  the  so-called  fractures, 
however,  it  is  practically  impossilile  to  accept  such  an  explanation  as 
that  given  above.  The  difficulties  have  been  recognised  liy  many 
writers,  who  have  attempted  to  explain  them  away  by  affirming  that 
the  membranes  have  ruptured,  letting  the  liquor  amuii  escape,  that 
the  solution  of  o.sseous  continuity  has  been  due  to  contrc-rouji  and  not 
to  direct  violence,  or  that  stormy  contractions  of  the  ftetal  muscles 
have  been  active  in  producing  the  fractures.  But  these  exjilanations 
are  all  more  or  less  unsatisfactory,  and  they  fail  more  particularly  in 
the  not  infrequent  cases  in  which  the  fractures  are  accompanied  by 
various  malformations.  Max  Sperling  (Ztschr.  f.  Geburtsh.  u.  Gi/naL. 
xxiv.  225,  1892)  has  recognised  this,  and  has  gone  boldly  in  (piile 
another  direction  to  find  an  adequate  pathogenesis :  to  this  matter 
reference  will  immediately  be  made.  It  has  been  noted  that  many 
of  the  so-called  fractures  are  represented  at  liirth  by  sharp  bendings 
on  the  bones,  and  that  over  the  angle  thus  formed  are  cutaneous 
cicatrices  ;  it  has  also  been  observed  that  there  have  existed  coincident 
malformations,  such  as  the  absence  of  one  or  more  digits  (IJ.  L.  Swan, 
Med.  Press  and  Circ,  n.s.,  xxvii.  160,  1879  ;  Danyau,  Bull.  Soc.  de  cliir. 
dc  Par.,  iv.  271,  1853-4;  Sachse,  Journ.  d.  pract.  Hedk.,  xi.  3  St., 
107,  1801),  and  sometimes  of  the  filnila  as  well  (Danyau,  loc.  eil. : 
Ithen,  Bis-firt.,  /iirici),  1885),  absence  of  some  of  the  tar.snl  bones, 
imperfect  formation  of  bones  contiguous  to  the  fractureil  one,  liarc- 
lij),  cleft  palate,  hydrocejjhalus,  club-foot,  club-hand,  median  fi.ssurc 
of  the  nose,  congenital  amjmtations,  amniotic  adhesions,  syndactyly, 
etc.  It  is  not  jiossilile  to  imagine  that  these  various  malformations 
can  have  arisen  from  traumatism,  aiid  yet  their  frequent  association 
with  the  so-called  fractures  must  be  explained  in  some  way.     The 


FGETAL   FRACTURES  395 

way  that  Sperling  {loc.  cit.)  takes  is  as  follows:  He  points  out  the 
fre(iuency  of  the  coexistence  of  the  so-called  badly  united  fractures 
anil  other  malformations,  and  indicates  that  in  most  instances  the 
malformations  cannot  be  regarded  either  as  the  causes  or  the  resuRs 
of  the  fractures ;  he  looks  for  a  cause  which  shall  be  common  to  lioth 
the  malformations  and  the  fractures.  In  order  to  find  this  common 
cause,  he  goes  back  to  the  first  and  second  months  of  intrauterine 
life,  to  the  endjryonic  period  in  fact,  and  finds  there  an  explanation 
m  defective  formation  of  the  annuon.  He  shows  that  the  cicatrices 
occasionally  found  near  such  fractures,  as  well  as  the  so-called  wounds 
{vide  absence  of  skin,  p.  328)  and  the  various  concomitant  malforma- 
tions, can  all  lie  accounted  for  by  tiie  action  of  amniotic  adhesions  or 
defective  developments.  I  tliink  it  is  necessary,  as  Sjierling  indicates, 
to  regard  most  of  the  so-called  fo'tal  fractures  as  originating  before 
the  truly  fcctal  period  of  antenatal  life,  and  possibly  by  the  mechanism 
of  amniotic  adhesions  or  pressure  (although  it  must  not  be  forgotten 
that  in  the  human  subject  the  development  of  the  anmion  has  not 
yet  been  elucidated) ;  but,  in  cases  such  as  Linck's  and  Chaussier's,  it 
seems  sufficient  to  regard  the  multiple  solutions  of  continuity  as  the 
result  of  extraordinary  fragility  of  the  liones,  accompanied  perhaps  by 
excessive  fVrtal  movements  or  stormy  uterine  contractions.  Hence  it 
comes  about  that,  in  order  to  explain  the  origin  of  the  so-called  fcetal 
fractures,  it  is  necessary  to  invoke  the  aid  of  embryonic  pathology  or 
to  postulate  the  existence  of  a  foetal  bone  disease. 

Foetal  Wounds  and  Dislocations. 

Under  the  heading  of  "  Congenital  Absence  of  the  Skin  "  (p.  328),  I 
have  already  considered  foetal  •'  wounds,"  and  have  pointed  out  their 
probable  amniotic  origin.  Doubtless  in  rare  cases,  and  specially  in 
grave  maternal  traumatisms,  the  foetus  may  lie  wounded  in  a  more 
direct  fashion ;  but,  to  explain  the  so-called  wounds  or  areas  showing 
absence  of  skin,  the  same  mechanism  has  to  be  invoked  as  for  fcetal 
fractures,  namely,  imperfect  development  of  the  amnion  (vide 
F.  Ahlfeld,  Eine  ncue  typische  Form  durch  amniotische  Fadcn 
hcrvorgcbraclder  VcrUldung,  Wien,  1894).  The  question  of  the 
ftetal  dislocations  is  less  easy  of  solution.  The  reader  is  referred  to 
the  paragraph  dealing  with  "Dislocations  in  the  New-l)orn  Infant" 
(p.  49)  for  a  statement  of  the  views  that  have  been  held  regarding 
the  causation  of  f(ctal  dislocations,  and  more  especially  of  congenital 
dislocation  of  the  hip.  In  these  morbid  states  the  iutranatarfactor 
is  often  with  difficulty  excluded,  and,  according  to  a  theory  which  still 
can  count  supporters,  it  is  by  traumatism  during  delivery  that  con- 
genital dislocation  of  the  liip'is  produced.  If  we  adnut  that  it  may  some- 
times be  thus  produced,  it  must  also  be  maintained  that  it  is  certainly 
not  always  so ;  for  both  in  the  case  of  the  liip  and  in  that  of  the  other 
joints  there  are  frequently  present  morbid  or  malformed  states  of  the 
articulation  which  certainly  arose  long  Jjefore  the  supervention  of 
labour.  Of  course,  it  may  be  argued  that  the  malformations  indeed 
were  present,  but  that  the  actual  dislocation  of  the  articidar  surfaces 


396  ANTENATAL    I' \l  1 1(  )I.()(i^'    AND    IlYCIl'.NK 

did  not  occur  till  the  process  of  parturition  had  commenced ;  but 
this  view  is  hardly  tenable  when  the  condition  of  the  parts  im- 
mediately after  birth  is  taken  into  account.  With  regard  to  the 
possible  occurrence  of  dislocations  in  fo'tal  life  due  to  violence,  and 
taking  place  in  articulations  not  previously  malformed  or  diseased,  it 
is  very  diftieult  to  speak  with  assurance ;  they  are  possible,  but  1  do 
not  think  that  many  fo'tal  dislocations  arise  in  this  way.  It  is  very 
prol)able  that  it  will  be  found  neces.sary  to  explain  most  of  the  dis- 
locations as  we  explain  most  of  the  fractures  in  utero,  by  su]i])osing 
that  they  occur  in  the  first  two  or  three  months  of  antenatal  life,  and 
that  imperfect  development  of  the  amnion  is  the  most  impor(a!it 
pathogenetic  factor  in  their  production.  They  are,  therefore, 
traumatic  only  in  the  limited  and  peculiar  sense  of  being  due  to 
possible  pressure  of  a  long-continued  kind  brought  to  bear  upon  the 
joints  by  the  attached  or  apposed  amnion.  They  also,  tlierefore,  are 
teratological  rather  than  traumatic ;  we  might  perhaps  say  that  they 
are  teratologically  traumatic,  if  such  an  expression  be  permissilile. 

Spontaneous  or  Congenital  Amputations. 

It  is  long  since  the  idea  of  the  truly  traumatic  origin  of  the 
so-called  congenital  or  spontaneous  amputations  came  to  be  doubted. 
The  notion  that  fracture  of  one  of  the  limbs  occurred  in  utero,  and 
that  thereafter  there  was  sharp  Hexure  of  the  part  with  ultimate 
separation  of  it  from  the  trunk,  cannot  be  accepted  at  the  present 
time.  It  is  necessary  to  find  some  other  explanation  for  the  cases  in 
which  an  infant  is  born  minus  a  hand,  a  foot,  some  fingers  or  toes,  oi' 
even  a  whole  limb,  and  in  which  there  is  a  well-formed  surgical 
stump  with  occasionally  some  little  projections  on  the  surface  of  it, 
which  have  been  regarded  as  rudimentary,  reproduced  digits.  At 
first  it  was  thought  that  a  sutticieut  explanation  had  been  found 
in  the  constricting  efl'ccts  of  the  umbilical  cord,  and  the  idea  of 
funic  pressure  produced  by  the  coiling  of  the  cord  round  a  lindi  or  a 
digit  was  advanced  and  maintained.  It  was  thought  that  in  early 
fcetal  life  the  tissues  of  the  part  and  even  the  bone  would  ultimately 
yield  before  the  long-continued  pressure  of  the  umbilical  cord,  tliat  au 
ever  deepening  groove  would  be  prodviced,  and  that  finally  actual 
separation  of  the  distal  part  would  take  place.  Cases  were  found  in 
which  a  groove  existed,  and  in  which  the  cord  was  found  occupying 
the  groove,  and  these  were  at  once  accepted  as  intermediate  stages  in 
the  production  of  the  amputation.  The  amputations  were  traumatic, 
therefore,  Init  it  was  an  umbilical  or  funic  traumatism  that  was 
understood.  Gradually,  however,  it  began  to  be  recognised  that 
there  were  grave  difficulties  iu  the  way  of  the  acceptance  of  the 
above  view,  such  as  the  softness  of  the  umbilical  cord,  the  absence  of 
the  amputated  part,  etc.  Tiiere  was  in  ])rocess  of  time  a  modification 
of  the  theory,  according  to  which  the  traumatic  j)ressurc  was  su]iplicd 
by  amniotic  adhesions  or  bands.  Tliis  was  and  still  is  a  jiopidar 
theory  of  origin  of  the  congenital  amputations.  There  is  no  doubt 
whatever  of   the    occurrence   of   these   amniotic    bands ;   they   are 


CONGENITAL   AMPUTATIONS  397 

frequently  found  associated  with  congenital  amputalions,  and  in 
many  respects  they  fulfil  the  requirements  of  the  case.  It  is  true 
that  they  are  also  often  absent  when  amputations  are  present,  and 
that  they  are  also  associated  with  all  kinds  of  malformations  and 
monstrosities :  but  it  was  possible  to  explain  away  these  dillicidties. 
The  bands  might  have  been  absorbed  after  they  had  performed  their 
amputating  etl'ects,  and  so  on.  Gradually  tlie  idea  arose  that  perhaps 
the  amniotic  bands  set  up  special  pathological  changes  in  the  skin  of 
the  constricted  part  in  the  position  of  the  constriction,  and  that 
the  pathological  changes  led  to  annular  amputation ;  it  was  thought 
that  a  sort  of  epidermic  dactylitis  was  set  up,  and  that  the  disease 
and  not  the  amniotic  band  cut  its  way  through  the  tissues  of  the 
limb.  Ainhuni  was  adduced  as  a  disease  which,  occurring  in  the 
adult,  produced  similar  constrictions  and  amputations,  and  did  so  by 
means  of  changes  in  the  skin  of  the  part.  Soon  a  slight  modification 
of  the  theory  came  to  be  adopted,  and  in  the  case  of  congenital 
amputations  it  was  no  longer  thought  that  the  amniotic  bands  were 
essential,  but  it  was  maintained  that  the  morbid  alterations  in  the 
skin  were  eminently  so.  Jeannel  {Arch,  dc  toco!.,  xiii.  774,  1886),  for 
instance,  held  this  view  :  for  he  found  it  difficult  to  understand  how 
the  amniotic  adhesions  were  produced,  and  he  could  not  explain  why 
the  depressions  were  always  circular  and  not  spiral,  and  why  the 
amputations  were  not  multiple ;  he  thought  it  more  probable  that 
the  grooves  and  the  amputations  were  both  trophic  lesions  of  a 
sclerodermic  nature.  L.  Eaynaud  (Journ.  dc  mal.  cutan.  et  sypli.,  2  s., 
vii.  193,  1895)  held  similar  views ;  but  J.  Eouget  {TMse,  Paris,  1889) 
and  De  Brun  {Scmainc  mcd.,  xiv.  397,  1894)  thought  that  ainhum 
and  congenital  amputations  had  nothing  in  common.  As  a  matter  of 
fact,  it  cannot  be  said  that  any  satisfactory  explanation  of  the  produc- 
tion of  the  so-called  spontaneous  amputations  has  yet  been  advanced. 
I  believe  that  they  are  produced  or  initiated  before  the  truly  fcetal 
period  of  antenatal  life,  and  that  they  are  connected  with  mal- 
development  of  the  amnion :  further,  I  am  hopeful  that  when  new 
light  is  thrown  upon  the  exact  mode  of  origin  of  the  amnion  in  the 
human  subject,  the  whole  question  of  the  teratogenic  efiects  of 
anomalies  in  its  development  will  receive  illumination. '^  Till  that 
time  come,  we  must  be  content  to  speak  somewhat  vaguely  of 
amniotic  action,  adhesions,  bands,  and  the  like.  At  the  same  time, 
congenital  amputations  must,  I  think,  be  regarded  as  teratological 
rather  than  traumatic  in  their  origin,  as  belonging  to  the  jjathology 
of  the  embryo  rather  than  to  that  of  the  fretus. 

'  If,  for  instanoi".  Berry  Hart'.s  idea,  stated  at  a  meeting  of  the  Edinlnirgli  Patho- 
logieal  Club  (Noyember  1901)  prove  to  be  correct,  much  that  is  at  present  ilitticult  of 
e.\p]aiiation  will  become  perceptibly  easier  ;  he  is  of  opinion  that  the  amniotic  cavity 
is  formed  by  the  ingrowth  and  subsequent  breaking  down  of  a  plug  of  epiblast  in  the 
enibr3-onic  area  of  the  blastodermic  vesicle. 


398  ANI'F.XA'I'Al,    rAIIIOI.OCV    AM)    IIVCJIENE 

Diseases  of  the  Foetal  Annexa. 

In  \ariiiiis  ]iarts  nf  iJiis  wiirk  ivfrrrncc  lias  been  alrrady  iiiailo  to 
llie  morbitl  states  nf  the  fn'tal  annexa  (tlic  placenta,  unihilieal  curd, 
chorion,  amnion,  and  liquor  aninii)  which  occur  in  association  with 
various  diseases  of  the  fu'tus.  I  have,  for  instance,  spoken  of 
I)lacental  tuberculosis  and  syphilis,  of  the  state  of  the  jilacenta  in 
maternal  leukamia  and  in  general  f<ctal  dropsy,  of  hydramnios,  and 
of  oligohydramnion.  There  can  be  no  doubt  that  this  association  of  the 
fiptal  morbid  changes  with  those  of  the  annexa  is  the  correct  plan  to 
adopt  in  order  to  understand  the  ])athology  of  the  fcctus,  for,  as  has 
already  been  emphasised,  the  jjlacenta  and  membranes  are  organs  of 
the  fcctus  as  much  as  its  intracorporeal  viscera,  at  any  rate  a  large 
part  of  the  ])lacenta  certainly  is  so.  In  order  to  obtain  a  comj)lete 
representation  of  the  pathology  of  any  fictal  disease,  it  is,  therefore, 
necessary  to  consider  together  the  morbid  anatomy  of  both  the  foetus 
and  its  annexa.  In  process  of  time  it  will  no  doubt  be  possible  to 
state  what  morbid  changes  in  the  placenta  are  commonly  associated 
with  the  various  transmitted  or  idiopathic  diseases,  toxicological 
states,  and  ill-defined  toxinic  conditions  of  the  f(ctus,  as  well  as  the 
maladies  which  are  accompanied  by  hydramnios  or  by  oligo- 
hydramnion. Unfortunately  it  is  at  present  quite  impossible  so  to 
do,  and  the  changes  in  the  ftctal  annexa  are  commonly  discussed 
as  if  they  were  independent  lesions.  Sometimes,  perhai)s,  they  are 
independent ;  sometimes,  also,  they  are  due  to  maternal  conditions, 
and  are  effective  in  producing  f(ctal  diseases  ;  but  very  often  they  are 
so  intimately  bound  up  with  the  pathology  of  the  unborn  infant  as  to 
be  inexplicable  ajiart  from  it. 

It  is  not  my  purpose  here  to  consider  all  the  morbid  states  of  the 
fcctal  annexa.  Some  are  evidently  of  the  nature  of  malfnrmations, 
and  will  be  described  under  the  Pathology  of  the  Embryo :  others 
have  been  already  described  under  the  various  diseases  of  the  fcetus 
{e.g.,  syphilis,  tuberculosis,  general  anasarca),  and  under  the  maternal 
maladies  which  have  prejudicial  but  ill-defined  effects  on  the  fa>tus 
{e.g.,  eclampsia) :  others  arise  during  the  earliest  part  of  antenatal  life, 
and  belong  to  (Jcrminal  Pathology;  while  yet  others  will  fall  to  be 
dealt  with  in  the  next  chapter  under  the  subject  of  F(ctal  Death. 
There  remain  some  morbid  states  of  the  annexa,  and  more  especially 
of  the  placenta,  which  require  a  passing  notice. 

Placental  Haemorrhages. 

Placental  lucmorrhages  or  "  apoplexies  "  occur  either  in  the  form  of 
diffused  elfusious  of  blood  into  the  tissue  of  the  placenta,  or  in  that  of 
more  or  less  circum.scribed  haemorrhages  in  more  or  less  well-defined 
cavities.  These  elfusions  may  be  found  either  on  the  fictal  or  on  the 
maternal  surface  of  the  placenta,  or  at  various  depths  in  its  substance ; 
they  may  be  numerous,  although  it  is  unusual  to  find  moie  than  two 
or  three  ;  they  vary  from  microscopic  dimensions  up  to  the  size  of  a 
hen's  egg  or  even  larger;  they  are  more  or  less  round  in  sJiapc:  and 


PLACENTAL   H.EMORRHAGES  399 

they  may  consist  of  recent  blood,  recent  clot,  old  clot,  fibrous  tissue, 
or  even  of  calcareous  material.  Sometimes  blood  in  various  stages  of 
alteration  may  be  found  in  the  same  hainorrliagic  patch.  The  lileed- 
ing  has  most  often  been  from  the  maternal  vessels,  and  the  villi  with 
their  vessels  are  compressed  thereby;  possibly,  however,  it  sometimes 
comes  from  the  fiL-tal  \'essels.  It  is  commonly  stated  that  the  chief 
causes  of  the  placental  apoplexies  are  maternal  traimiatism  and 
maternal  disease,  and  under  the  latter  head  are  grouped  renal  and 
cardiac  maladies  and  the  fevers.  Their  microbic  or  toxiuic  origin  has 
lately  been  much  insisted  upon  by  S.  Satullo  (Arch,  di  ostet.  e ginec.,\. 
193,'399,  518,  577,  1898),  and  F.  Caruso  {ibid.,  vi.  129,  1899),  and  it 
is  probable  that  they  often  are  produced  in  this  way,  for  bacteria  are 
not  unconunonly  found  in  them.  Thej'  may  thus  have  a  very  con- 
.siderable  influence  upon  the  transmission  of  maladies  from  mother 
to  fa'tus,  or  from  ftetus  to  mother;  but  in  all  probability  they 
themselves  are  simply  incidents  in  systemic  infections  afiecting  the 
mother  or  the  foetus  or  both.  They  may  lead  to  the  immediate 
expulsion  of  the  uterine  contents,  or  they  may  kill  the  foetus  which 
is  expelled  later,  or  they  may  produce  effects,  the  nature  of  which 
is  little  known,  upon  the  nutrition  of  tlie  fo-tus,  or  they  may  appa- 
rently cause  no  evil  consequences  at  all.  The  result  will  depend 
upon  many  circumstances,  such  as  the  amount  of  blood  poured  out, 
the  area  of  the  placenta  affected,  the  condition  of  the  fo'tus,  and 
the  like.  Sometimes  it  is  very  puzzling  to  account  for  anomalous 
cases  in  which  large  eflu.sions  have  caused  no  visible  bad  effects,  or 
in  which  small  h;emorrhages  have  apparently  had  far  -  reaching 
consequences.  It  has  always  to  be  borne  in  mind  that  a  limited 
view  of  the  subject  will  give  no  trustworthy  results.  I  have  often 
insisted  upon  the  necessity  of  examining  the  placenta  in  all  cases  of 
foetal  disease ;  but  it  is,  of  course,  equally  or  more  important  to 
examine  the  infant  and  mother  in  all  cases  of  placental  disease.  It 
is  only  by  making  a  broad  survey  of  such  phenomena  that  one  can 
arrive  at  satisfactory  conclusions. 

Under  the  name  of  fihro-fatty  degeneration  of  the  placenta  have 
been  described  certain  changes  more  particularly  affecting  the  chor- 
ionic villi,  which  lead  to  the  formation  of  yellowish  white  jiatches 
in  the  placental  substance.  These  are  not  infrequently  found  in 
the  full  time  placenta  in  small  numbers  and  of  limited  size :  they 
are  then  regarded  as  physiological  or  as  signs  of  placental  senility. 
When,  however,  they  are  numerous,  or  when  they  occupy  a  large 
part  of  the  substance  of  the  afterbirth,  they  are  admitted  to  be 
pathological.  In  this  respect  they  resemble  the  placental  hemor- 
rhages, for  they  also,  when  small  and  limited  in  number,  have  been 
looked  upon  as  preparatory  changes  to  make  easy  the  separation 
of  the  afterbirth  at  the  time  of  labour.  They  consist  in  a  fibrous 
transformation  of  the  villi  of  the  chorion,  with  diminution  in  the 
size  of  the  vessels,  and  consequent  atrophy  of  these  villi.  Here 
and  there  fatty  changes  are  produced.  It  may  be  that  these  changes 
are  the  results  of  the  ha-morrhages  which  have  been  described  above, 


400  ANTENATAL    I'ATIIOI.OCY    AND    HY(;iKM', 

bill  all  autlioi-s  do  not  adniil,  lliis.  It  is  snuietiines  very  .sui'jirising 
to  find  to  what  a  large  extent  tlie  placenta  may  he  transt'ornied  into 
this  fibro-fatty  material,  ami  yet  the  infant  be  born  alive,  healthy, 
and  well  nourished.  In  a  recent  case  at  the  Edinburj^h  ]\Ialeniity 
Hospital,  I  noted  that  fully  two-thirds  of  the  iilacenta  were  thus 
altered,  and  yet  the  child  not  only  survived  birth,  but  throve  well. 
Calcareous  deposits  on  the  uterine  surface  of  the  placenta  have  no 
pathological  significance ;  so  at  least  it  is  commonly  believed. 

Various  luurhid  conditions  of  (he  umhiiieal  cord  have  been  desciribed, 
although  it  is  doubtful  how  far  any  of  them  can  be  looked  upon  as 
diseases.  Excessive  torsion  has  been  met  with  in  which  the  cord 
has  become  thread-like  at  the  twisted  part.  The  fu'tus  is  then 
usually  dead  ;  but  the  torsion  is  not  now  admitted  to  be  of  necessity 
the  cause  of  death,  for  it  has  been  suggested  that  it  may  be  the 
result  of  it  on  account  of  the  exaggerated  mobility  in  utero  of  a 
ftetus  which  dies  about  the  mid-term  of  pregnancy.  The  cord  may 
be  coiled  round  the  infant  in  various  ways,  and  even  many  times. 
In  a  ftetus  which  occurred  in  the  practice  of  Professor  J.  A.  C.  Kynoch 
of  Dundee  {Trans.  Edinh.  Obsf.  ,Sor.,  xx.  1,  1895),  there  were  six  coils 
round  the  neck.  When  the  unborn  infant  slips  through  such  a  loop 
or  through  several  loops  of  the  cord,  knots  of  various  degrees  of  com- 
plexity may  be  pi'oduced,  and  sometimes  apparently  these  knots 
may  be  drawn  so  tight  as  to  interfere  with  the  continuance  of 
antenatal  life.  In  the  case  of  twins  in  a  common  amniotic  cavity, 
some  exceedingly  curious  entanglements  have  occurred  between  the 
two  cords  and  the  two  foetal  bodies  (ride  E.  Fricker,  l/cbcr  t'crsch- 
linqunij  und  Knotenhildung  dcr  Nahclschnilre  hei  ZwiUingsfruchten, 
Tubingen,  1870). 

Hydramnios. 

Hydramnios,  or  excess  of  the  liquor  amnii  (more  than  two  pints 
at  full  term),  is  so  commonly  associated  with  iwiaX  morliid  states, 
as  to  suggest  by  its  presence  the  existence  of  one  or  other  of  these 
states.  At  the  same  time  it  has  to  be  noted  that  it  may  be  met 
with  when  neither  the  foetus,  nor  the  foetal  annexa,  nor  the  motlier 
herself,  shows  any  sign  of  a  pathological  process.  Reference  has 
already  been  made  to  hydramnios  in  this  work ;  for  it  may  occur 
in  conjunction  with  nearly  every  one  of  the  maladies  (transmitted, 
toxinic,  idiopathic,  traumatic)  which  have  been  described.  Special 
attention  was  called  to  its  presence  in  syphilis ;  but  it  is  met  with 
also  in  general  foetal  dropsy,  in  fo>tal  ichthyosis,  in  firtal  ascites, 
in  fietal  bone  ilisease,  etc.  etc.  So  often  is  it  a  concomitant  of 
fu'tal  maladies,  that  it  cannot  be  regarded  as  pathognomonic  of  any 
special  one  of  them.  Further,  it  is  very  frequent  in  connection 
with  the  manifestations  of  embryonic  and  germinal  pathology,  for 
it  is  found  associated  with  all  kinds  of  monstrosities  and  malforma- 
tions, and  with  twins  and  triplets.  It  is  also  met  with  in  grave 
maternal  states,  such  as  albuminuria  and  hyperemesis,  but  whether 
as  effect,  or  symptom,  or  cause,  cannot  yet  be  securely  determined. 


HYDRAMNIOS  401 

Its  very  frequency,  then,  is  a  hindrance  to  our  understanding  of 
its  origin  and  significance.  Like  pain  in  adult  maladies,  lilve  con- 
vulsions in  infants,  hydramnios  in  antenatal  life  may  indicate  many 
different  conditions  of  varying  degrees  of  gravity,  and  apparently 
it  may  in  some  instances  exist  as  itself  the  sole  pathological  mani- 
festation. The  liquor  amnii  is  the  immediate  envii-oument  of  the 
fcetus,  it  is  indeed  the  fcetal  hydrosphere :  and  variations  in  its 
quantity  come  to  be  the  most  delicate  tests  of  the  inter-relation 
between  the  maternal  and  fcetal  economies.  Of  variations  in  its 
quality  little  can  be  said ;  with  the  exception  of  some  few  observa- 
tions upon  the  presence  of  sugar  and  drugs  in  it,  and  of  fairly 
numerous  records  of  cases  of  fo'tal  death  in  which  it  was  stained 
with  meconium,  our  knowledge  of  the  qualitative  anomalies  of  the 
liquor  amnii  is  nil.  I  have  met  with  a  case  in  which  it  was  opacjue 
and  white  like  milk,  and  yet  the  infant  was  born  alive  and  healthy ; 
under  the  microscope  it  had  the  appearance  of  diluted  pus ! 

The  clinical  history  of  cases  of  hydramnios  varies  within  the 
widest  possible  limits.  The  mother  may  apparently  have  enjoyed 
perfect  health  up  to  the  time  of  her  pregnancy;  she  may,  on  the 
other  hand,  have  suffered  from  syphilis,  an;emia,  heart  disease,  or 
renal  disease.  There  may  be  no  history  of  the  previous  occurrence 
of  hydramnios  in  the  reproductive  life  of  the  mother  (C.  E.  Stokes, 
Brit.  Med.  Jonrn.,  i.  for  1895,  p.  To),  or  there  may  be  a  record  that  it 
has  repeatedly  complicated  pregnancy.  There  may  be  a  good  family 
history  or  a  bad.  With  regard  to  the  >iymptomatolo(jy  of  the  preg- 
nancy complicated  by  hydramnios  there  is  also  some  difference  in 
details.  There  may  be  the  history  of  an  abdominal  traumatism, 
followed  by  the  sudden  development  of  a  high  degree  of  hydramnios ; 
on  the  other  hand,  there  may  be  no  record  whatever  of  any  injury  or 
blow,  and  the  excess  of  amniotic  fluid  has  apparently  been  slowly 
produced.  The  condition  may  occur  early  in  pregnancy  (as  early 
as  the  second  month),  or  it  may  come  on  late ;  liut  mid-term  (fifth 
month)  seems  to  be  the  period  of  predilection.  It  maj'  be  accom- 
panied by  hypei'emesis,  by  dropsical  conditions,  by  the  symptoms 
of  albuminuria,  by  fever,  by  constipa,tion  and  jaundice,  b}'  neuralgias 
and  insomnia,  by  dyspncea,  by  palpitation  and  syncope,  and  sometimes 
by  diarrhcea.  The  more  rapidly  the  hydramnios  is  produced  the  more 
marked  are  the  symptoms  caused :  as  a  matter  of  fact,  fever  is  probably 
absent  save  in  the  more  acute  cases.  The  degree  of  distress  may 
become  quite  unbearable,  and  it  may  sometimes  be  necessary  at  once 
to  diminish  the  quantity  of  liquor  amnii  in  the  uterus. 

The  -physical  signs  are  usually  quite  distinctive.  The  abdominal 
enlargement  is  too  great  for  the  period  of  pregnancy  arrived  at ; 
thus  at  the  fifth  month  the  size  of  the  abdomen  may  correspond 
with  that  usually  attained  at  the  full  term.  The  swelling  also  is 
more  globular  than  usual,  and  occupies  the  middle  line  of  the 
abdomen ;  there  is  dulness  on  percussion  over  it,  but  the  flanks 
give  a  tympanitic  note,  and  the  area  of  dulness  does  not  change 
its  position  when  the  patient  turns  on  her  side.  Palpation  generally 
at  first  suggests  fluid  in  an  ovarian  cyst  or  free  in  the  abdominal 
26 


402  ANTHNATAI.    I'AI'I  lOI.OClV    AM)    inClFA'E 

cavity ;  but  now  and  again  contractions  sweep  over  the  surface  of 
the  distemleil  uterus,  giving  it  a  temporary  lianluess  and  allording 
a  valuable  diagnostic  indication.  Fluctuation  is  usually  obtained 
easily,  and  Ijallottenient  (both  vaginal  and  abdominal)  may  be  elicited, 
but  not  with  the  facility  that  the  presence  of  a  small  fictus  in  a  large 
amount  of  liquor  amuii  would  suggest.  It  is  often  very  difficult, 
either  by  abdominal  palpatinn  or  by  the  bimanual  examinatinn,  to 
recognise  the  head  and  other  pints  of  the  firtus,  a  result  due  in  part 
to  the  elusiveness  of  the  unborn  infant,  wliicli  in  its  large  liydro- 
sjihere  slips  away  so  quickly  out  of  the  hands  of  the  obstetrician. 
Auscultation  may  give  negative  results,  Init  sometimes  both  tlie 
ftetal  heart  and  the  uterine  souffle  can  be  heard.  The  mother  may 
herself  be  ([uite  unconscious  of  fo'tal  movements.  It  may  be  noted 
further,  although  tlie  signs  are  of  less  importance,  that  the  alxlominal 
walls  are  either  very  thin  or  are  markedly  o'dematDUS,  tliat  dropsical 
swelling  of  the  labia  and  of  tlie  lower  limbs  is  common,  and  that 
circulatory  troubles,  such  as  varicnse  veins  ami  lucmnrrlKjids,  are 
often  met  with.  Albuminuria  may  be  met  with,  but  is  nut,  of 
course,  pathognomonic. 

From  the  symptomatology  and  physical  signs  the  obstetrician 
.attempts  to  form  his  dia/piosia.  He  is  at  once  met  with  dilliculties. 
In  the  first  ])lace,  he  is  led  by  the  absence  of  many  of  its  signs  and 
symptoms  to  doubt  the  existence  of  pregnancy  at  all,  and  to  think 
rather  of  an  ovarian  cyst  or  of  ascites.  A  careful  examination  ouglit 
usually  to  exclude  the  latter :  for  in  ascites  the  abdomen  is  more 
flattened,  being  distended  laterally,  and  the  dull  area  changes  with 
changes  in  the  position  of  the  patient;  the  intermittent  uterine 
contractions  are  absent ;  and  there  is  usually  some  cause  (e.g.  maternal 
heart  disease)  to  account  for  the  fluid  eti'usion  into  the  peritoneal 
cavity.  In  the  case  of  an  ovarian  cyst,  there  is  often  a  much  longer 
history  of  development,  and  there  is  sometimes  the  record  that  the 
swelling  was  unilateral  at  first ;  intermittent  hardening  of  the  swelling 
is  absent ;  and  a  careful  bimanual  reveals  tlie  uterus,  little  enlarged, 
lying  to  one  side  of  the  tumour.  The  second  diagnostic  difficulty 
is  met  with  after  the  obstetrician  has  made  up  his  mind  that  preg- 
nancy exists.  He  is  fairly  sure  that  he  is  dealing  with  pregnancy 
and  with  a  morliid  pregnancy ;  but  he  is  at  a  less  to  determine 
what  form  of  anomalous  gestation  it  is.  Is  it  pregnancy  complicated 
by  ascites  or  ovarian  cyst  ?  Is  it,  perhaps,  a  plural  pregnancy,  or 
a  hydatid  mole,  or  simply  a  very  large  infant,  or  a  fo'tus  enlarged 
by  some  malformation?  A  careful  consideration  of  all  the  facts 
will  lead  him  out  of  several  of  these  difficulties.  In  the  case  of 
the  hydatid  mole  the  uterus  is  somewiiat  pear-shaped  rather  than 
globular,  fluctuation  is  not  evident,  and  tliere  is  often  a  history  of 
repeated  vaginal  discharges  consisting  of  blood.  Wlien  there  is 
simply  a  large  fo'tus  (and  jdacenta),  or  a  large  and  grossly  malformed 
infant,  he  must  rely  upon  accurate  palpation  of  the  alulonu'n,  tlie 
slow  rate  of  the  fo'tal  heart  beat,  and  the  al)sence  of  fluctuation 
and  ballottement.  When  twins  are  in  the  uterus,  it  is  sometimes 
possible  to  be  sure  of  their  presence  by  the  shape  of  the  organ, 


HYDRAMNIOS  403 

by  tlie  palpation  nf  two  foetal  heads,  one  at  the  pelvic  brim  and 
the  other  at  the  fundus  or  at  the  side,  by  tiie  hearing  of  two  fcetal 
hearts,  eacli  with  its  own  rate  and  position  of  maximum  intensity, 
and  by  the  recognition  of  numerous  small  parts.  But,  in  the  diagnosis 
of  twins,  it  is  possible  with  the  greatest  care  to  go  far  astray.  When 
the  pregnancy  is  complicated  by  an  ovarian  cyst  lying  in  the  abdomen, 
it  will  often  lie  possible  to  detect  the  two  tumours  (the  ovarian  and 
the  uterine),  which  differ  in  consistence  and  shape,  and  to  note  that 
one  of  tlieui  is  more  or  less  central  in  position,  and  rises  out  of  the 
pelvis :  when  the  cyst  is  in  the  pelvic  cavity,  in  whole  or  in  pai't, 
a  very  careful  bimanual  will  be  needed,  and  even  then  it  may  be 
impossible  entirely  to  exclude  an  extrauterine  pregnancy.  By  some 
sucli  process  of  diagnostic  exclusion  the  obstetrician  may  be  able 
to  state  tliat  the  gestation  is  one  made  abnormal  by  reason  of 
hydrauHiios.  Finally,  however,  a  third  diagnostic  difficulty,  and  that 
an  almost  insuperalile  one,  arises  when  there  is  hydramnios  in  associ- 
ation with  twins,  or  with  ascites,  or  with  an  ovarian  cyst,  or  in  an 
extrauterine  gestation  sac.  Under  these  circumstances  the  best 
methods  in  the  best  hands  will  often  fail  to  differentiate  the  associ- 
ated morbid  states.  Not  until  laliour  commences,  and  the  cervix 
begins  to  dilate,  will  the  intrauterine  mystery  he  revealed.  But 
all  cases  do  not  belong  to  the  last  category ;  and  it  must  be  reniem- 
liered  that  it  is  often  easy  to  diagnose  hydramnios,  and  that  having 
diagnosed  it  we  ought  immediately  to  suspect  a  morbid  state  of  the 
unborn  infant. 

The  prognosis  of  hydramnios,  stated  in  a  very  few  words,  is  a 
delayed  labour  with  a  malpresentation,  a  dangerous  third  stage 
(on  account  of  uterine  inertia),  and  a  deformed,  diseased,  dead,  or 
at  least  a  puny  infant.  These  results,  however,  are  by  no  means 
constant.  Even  the  small  bulk  of  the  fcetus  is  not  always  noted ; 
indeed,  G.  Barbezieux  (These,  Paris,  1889)  found  that  out  of  232 
cases  of  hydramnios,  there  were  only  81  infants  which  were  below 
the  normal  minimum  in  weight  (the  normal  minimum  being  regarded 
as  2500  grms.).  It  must  also  be  taken  into  account  that  in  many 
cases  hydranniios  means  premature  labour.  At  the  same  time,  and 
making  allowance  for  this,  it  must  still  be  admitted  that  excess  of 
the  liquor  amnii  is  the  great  indication  of  pathological  conditions 
inside  the  pregnant  uterus. 

■  The  ]mtho!o/ji/  of  hydramnios  is  very  imperfectly  known.  Victor 
Guillemet  (y/ff-.sc,  Paris,  1876)  says  that  hydramnios  has  not,  properly 
speaking,  any  pathological  anatomy :  "  I'hydropisie  de  I'amnios  n'a 
pas,  a  proprement  parler,  d'anatomie  pathologique."  In  a  certain 
sense  this  is  quite  true,  for,  as  has  been  pointed  out,  there  is  no 
special  state  of  the  fcetus  or  of  the  mother  which  can  be  regarded  as 
the  constant  cause  (or  effect)  of  hydramnios.  There  are,  however, 
some  facts  regarding  the  state  of  the  placenta  and  memliranes  wliich 
must  lie  referred  to.  Sometimes,  as  in  the  s]iecinien  which  I  showed 
to  the  Edinburgh  Obstetrical  Society  in  1894  (170),  the  placenta 
exhibits  hypertrophy ;  sometimes  it  is  also  (edematous  (ride  p.  294), 
or  affected  with  syphilitic  changes  (vide  p.  230) ;  and  sometimes  it  is 


404  ANTENATAL    I'ATIIOIXXJY    AND    HYCilENE 

adherent  or  tlie  seat  of  tibro -adipose  degeneration.  But  none  of  these 
chanties  is  constant.  Sometimes  the  umbihcal  cord  is  longer  than 
usual,  much  coiled  round  the  foetus,  or  showing  marked  torsion ; 
sometimes,  also,  its  vessels,  and  esj)ccially  the  vein,  may  Ije  more  or 
less  narrowed  ;  but  in  other  cases  tiiese  changes  are  ali.sent.  Some- 
times the  cajiillary  network  ("  vasa  propria")  described  by  .linigliluth 
(Arch./.  Gijnaek.,  iv.  5o4,  1872),  which  lies  under  the  amnion  on  the 
fcKtal  surface  of  the  placenta,  has  l)een  noted  to  lie  very  evident — 
so-called  persistence  of  the  vessels  of  Jungbluth — but  in  many  cases 
these  vessels  are  not  to  be  seen.  Sometimes  the  amnion  and  ch(jrion 
are  thickened;  Init  sometimes  they  are  not.  It  is  quite  evident  that 
these  facts  regarding  tlie  jilacenta.  membranes,  and  cord  do  not  throw 
much  light  upon  the  pathology  of  the  disorder;  indeed,  they  dee})en 
the  shadow  in  which  the  subject  lies.  Neither  do  observations  on  the 
characters  and  chemical  composition  of  the  liquor  amnii  itself  help  us 
very  much,  for  they  are  very  few  in  numl>er :  sugar  may  be  present 
{tide  p.  223),  and  E.  Opitz  (Ccntrlbl.  /.  Gynak.,  xxii.  553,  1898) 
has  exjierimentally  shown  the  presence  of  an  irritating  (lymph- 
agogue)  substance  in  the  amniotic  fluid  in  cases  of  hydramnios ;  but 
there  is  great  need  for  much  more  investigation  of  this  important 
part  of  the  subject.  The  quantity  of  the  liquor  amnii  varies  from  a 
little  more  than  two  pints  up  to  such  enormous  amounts  as  seven, 
twelve,  seventeen,  and  even  twenty  litres.  The  pathology,  therefore, 
of  the  placenta,  memliranes,  cord,  and  liquor  amnii  is  not  known  with 
any  certainty ;  and  the  same  remark  applies  to  that  of  the  fo'tus  and 
mother  in  these  cases,  for  the  fa-tus  may  exhibit  practically  any,  all, 
or  none  of  the  various  diseases  and  deformities  by  which  it  may  be 
affected,  and  the  mutlier's  health  may  vary  from  very  good  to  very 
bad. 

It  cannot,  then,  be  expected  that  our  knowledge  of  the  patho<jcncsis 
of  hydramnios  will  be  in  any  measure  exact  or  sufficient.  Further, 
the  reader  will  remember  that  even  the  origin  and  source  of  the 
liquor  amnii  in  normal  pregnancies  are  matters  of  uncertainty  and  of 
great  difierence  of  opinion  {vide  p.  152,  et  scq.).  Some  writers  hold 
that  the  amniotic  fluid  has  a  purely  fcetal  origin,  some  a  purely 
maternal,  and  some  that  it  arises  from  both  fo'tal  and  maternal 
processes.  Similarly,  when  the  fluid  is  in  excessive  amount,  the  same 
different  theories  of  origin  have  been  advanced.  On  this  subject 
Paul  Bar's  Thhc  (Paris,  1881)  is  still  well  worth  consulting,  although 
now  twenty  years  old.  There  is,  fiir  instance,  the  idea  that  the 
liquor  amnii  is  fui'tal  urine,  and  that  hydramnios  indicates  increased 
renal  activity ;  but  the  kidneys  may  show  no  pathological  changes,  the 
urethra  may  be  occluded  or  al)sent  altogether,  aiul  there  may  even  be 
entire  absence  of  the  kidneys,  and  yet  the  fluid  be  jiresent  in  excessive 
amount.  Then  there  is  the  theory  that  various  skin  diseases  of  the 
fwtus  may  be  the  source  of  the  liydraninids,  and  a  few  cases  in  which 
pemphigus  or  nu'vus  or  other  morbid  states  havt'  coexiste<l  with 
liydramnios  have  been  cited;  liut  the  evidence  is  very  slight,  and  the 
coexistence  only  occasional.  A  more  }irobable  theory  looks  to 
increased  pressure  in  the  umbilical   vessels  (from   various   morbid 


HYDRAMNIOS  405 

cliauges  in  the  fretus  or  cord)  as  tlie  proliable  mode  of  origin  of 
hydraninios.  According  to  this  view  (to  which  reference  has  already 
been  made,  p.  232),  the  hydranaiios  of  antenatal  life  is  e(puvalentJ;o 
the  hepatic  ascites  of  adult  existence ;  the  pressure  in  the  umbilical 
vein  may  be  raised  liy  morliid  conditions  in  the  liver,  heart,  or  lungs 
of  the  fu'tus,  and  increased  transudation  of  fluid  take  place.  Again, 
it  has  been  supposed  that  the  excess  of  the  liquor  amnii  is  due  to 
a  secretion  from  the  cerebro-spinal  canal  of  the  fcetus,  and  cases  in 
which  that  canal  is  open  by  reason  of  grave  malformations  have 
been  adduced  in  support  thereof ;  but,  of  course,  such  malformations 
are  often  absent  when  hydraninios  is  present.  It  has  been  affirmed 
that  the  flaky  deposits  sometimes  seen  on  the  surface  of  the  amnion 
in  cases  of  hydraninios  indicate  the  occurrence  of  inflammation  of  that 
membrane  (Seiitex,  Mem.  et  hull.  Soc.  de  mM.  ch  Bordeaux,  204,  224, 
1869),  and  that  the  "amniotitis"  thus  produced  has  caused  excessive 
secretion  from  the  membrane  in  some  such  way  as  pleurisy  with 
effusion  takes  place.  This  explanatitm  has  been  specially  advanced 
in  cases  where  the  liydramnios  has  followed  a  blow  or  fall,  and  it 
has  been  alleged  that  the  traumatism  was  the  exciting  cause  of 
the  "  amniotitis  "  with  effusion.  There  are  diiBculties  in  the  way 
of  accepting  this  view,  such  as  the  non-vascular  character  of  the 
amnion ;  but  there  is  some  reason  to  regard  the  explanation  as 
sufficient  in  certain  cases  (acute).  Further,  the  structure  of  the 
amnion  permits  the  supposition  that  lymph  may  pass  easily  enough 
through  it  I  )y  the  stomata.  It  is,  therefore,  not  impossible  that  in  some 
of  the  chronic  cases,  also,  there  may  be  a  transudation  of  serum  from 
the  maternal  vessels  through  the  membranes  into  the  amniotic  cavity, 
e.g.,  in  instances  of  maternal  nephritis,  ana-mia,  etc.  But,  again,  in 
twins,  and  especially  in  uniovular  twins,  hydraninios  may  occur  in 
association  with  one  but  not  with  the  other;  this  is  an  occurrence 
which  has  been  explained  by  some  writers  as  due  to  the  weaker  heart 
of  the  fojtus  with  liydramnios,  an  explanation  found  difticult  of 
acceptance,  since  that  foBtus  may  apparently  have  the  stronger  heart 
of  the  two. 

One  might,  however,  write  much  on  the  various  pathogenetic 
theories  which  have  arisen  round  the  suliject  of  hydraninios,  and  yet 
do  little  or  nothing  to  simplify  the  problem.  I  shall  content  myself 
with  making  two  statements,  and  then  closing  the  discussion,  so  far 
at  any  rate  as  the  pathology  of  the  foetus  is  concerned.  In  the  first 
place,  it  has  to  be  borne  in  mind  that  hydramnios  is  simply  the 
jiersistence  of  a  state  which  is  normal  in  the  early  months  of 
pregnancy,  for  at  the  fourth  month  the  liquor  amnii  weighs  more 
than  either  the  fcetus  or  the  placenta  and  mendiranes.  We  may 
then  regard  hydramnios  as  the  persistence  or  rejiroduction  of  a 
relationship  between  the  foetus  and  its  hydrosphere,  which  is  normal 
in  early  fretal  life,  and  perhaps  also  in  neofa;tal  existence.  In  the 
second  place,  the  frequent  association  of  hydraninios  with  so  many 
different  manifestations  of  both  fcetal  and  embryonic  pathology,  shows 
that  it  must  be  due  to  a  factor  which  is  common  to  these  different 
morbid  states,  or  else  to  a  very  large  number  of  different  causes.     I 


40G  ANTENATAL    I'ATHOLOdY    AND    HYdll.NK 

am  incliiieil  Id  a(;cc])t  the  lattev  alternative,  and  to  lonk  iquin 
hydramnios  as  a  syuiiitoni  nf  antenatal  jiatiiological  eonditions,  and 
to  regard  it  as  liavin;^  nrigin  in  several  dill'ereiit  ways.  It  may  some- 
times be  due  to  a  cheniical  irritant  eomin^  from  the  mother  or  formed 
in  the  foetus  which  excites  a  liow  of  lymiih  or  serum:  it  may  be 
caused  by  incTcased  pressure  in  the  undjilical  vein  and  its  brandies, 
arising  from  various  foetal  diseases  and  deformities ;  it  may  1)6  the 
result  of  changes  in  the  maternal  blood  which  allow  incieased  trans- 
udation ;  or  it  may  possibly  represent  fcetal  urine  or  cerebro-spinal 
liuid.  I'ossibly  the  new  method  of  investigating  fluids  by  the  diil'er- 
ence  in  their  freezing  point  may  thnnv  light  upon  the  origin  both 
of  the  normal  liquor  amnii  and  of  the  anniiotic  fluid  in  excess. 
G.  liesinelli  (A7m.  di  ostd.  r  i/inrc,  xxiii.  1029,  1901)  has  already 
published  the  results  of  re.searches  on  the  osmotic  pressure  of  the 
maternal  and  fretal  blood  and  of  the  liquor  amnii ;  he  has  found 
that  it  is  less  in  the  maternal  and  fietal  blood  at  birth  than  in 
the  non-pregnant  adult,  and  that  it  is  constantly  less  in  the  liquor 
amnii  than  in  the  maternal  or  foetal  blood.  Further,  in  a  case  of 
twins,  the  freezing  point  of  the  liquor  amnii  of  the  one  fo'tus  niaj' 
dilTer  from  that  of  the  other.  It  is,  therefore,  (piite  possible  that 
cryoscopy  (as  this  method  of  research  is  called)  may  yet  helj)  to 
clear  up  certain  problems  regarding  the  formation  of  the  li(iuor 
amnii  both  in  normal  and  abnormal  amount. 

The  treatment  of  hydramnios  has  generally  taken  the  form  of 
tapping  the  memliranes  through  the  cervix,  but  somewhat  high  up, 
so  as  to  allow  some  of  the  Huid  to  escape,  and  thus  to  relieve  the 
suffering  caused  by  the  over-distended  state  of  the  uterus.  Chloral 
and  morphia  have  been  used  as  sedatives.  It  is  possible  that  dietetic 
or  medicinal  measures  may  yet  prove  successful  in  arresting  the  over- 
secretion  of  the  anniiotic  Ikiid.  Mercury  and  iodide  of  potassium 
have  been  used.  In  one  instance  I  gave  saline  pui-gatives  with  this 
end  in  view ;  but,  since  a  few  days  later  laliour  supervened  and  twins 
were  born  slightly  prematurely  along  with  a  great  excess  of  liipior 
amnii,  one  could  not  say  whether  the  salines  had  any  ettect  u])on  the 
quantity  of  Huid,  although  they  may  have  hastened  the  adxcnt  of 
labour.  It  has  been  advised  that  only  the  smallest  quantity  of  Ihiid 
be  given  with  the  food  in  cases  of  hydramnios ;  but  of  course  it  will 
always  be  difficult  to  judge  of  results.  In  an  interesting  case  of  early 
(third  month)  hj'dramnios,  reported  by  A.  A.  Scott  Skirving  {Edinh. 
Hosp.  Rep.,  vi.  387,  1900),  in  which  the  abdomen  was  ojjened  on  the 
mistaken  diagnosis  of  ovarian  cyst,  the  hydramnios  slowly  disaiijieared 
after  the  abdomen  had  been  closeil  again,  and  at  the  full  (cnn  or  near 
to  it  the  jjatient  was  normally  delivered  of  a  living  infant,  there  being 
then  no  sign  of  hydramnios.  From  such  a  ease  we  are  led  to  believe 
that  reabsorption  of  an  excessive  amount  of  liquor  amnii  occurs,  and 
is  jierhajjs  to  be  ho]ied  for. 

Oligohydramnion. 

By  oligohyilramnioii  is  meant  th(>  absence  or  marked  defieieiicy 
of  liquor  amnii.      It  would  seem   to  Ijc  rarer  than  hydrainnios,  if  the 


OLIGOHYDRAMNION  407 

muaber  of  recorded  cases  be  taken  into  account.  J\ly  own  experience 
agrees  with  this  ;  bnt  it  is  probable  that  more  cases  of  ohgohydramnion 
escape  recording  than  of  hydranmios.  The  anomaly  varies  in  degree:; 
sometimes  onl}-  a  diachm  or  two  of  thick,  viscid  material  may  be 
found  representing  the  amniotic  fluid. 

It  might  be  hoped  that  a  study  of  the  cases  of  oligohydramnion 
woidd  thi'ow  some  light  upon  the  causes  and  pathogenesis  of 
hydramnios ;  possibly  it  does,  if  we  were  only  acute  enough  to  per- 
ceive it,  but  the  light  is  not  evident  to  us  as  yet.  For  it  is  found  on 
investigation  that  oligohydramnion  is  associated  with  very  much  the 
same  firtal  diseases  and  monstrosities  that  hydramnios  is.  For 
instance,  in  1895  I  reported  a  case  (176)  of  dilatation  of  the  urinary 
bladder  and  ureters  with  hydronephrosis  in  which  there  was  oligo- 
hydramnion ;  yet  in  other  cases  in  which  similar  anomalies  are 
present  there  may  be  hydramnios.  W.  W.  Jaggard  (Amcr.  Jonrn. 
Obst.,  xxix.  433,  1894)  also  reported  a  somewhat  similar  case,  in 
which  the  bladder  was  greatly  hypertrophied,  the  urethra  obstructed, 
the  right  kidney  cystic,  the  left  kidney  as  well  as  the  rectum  and 
anus  absent,  both  hip-joints  dislocated,  and  the  left  sterno-mastoid 
muscle  wanting.  Sometimes  the  fcetus  would  seem  to  be  normal  and 
is  born  alive  ;  sometimes,  on  the  contrary,  it  is  the  victim  of  various 
morbid  alterations,  including  fractures  (Linck,  Arch./.  Gynaek.,  xxx. 
264,  1887),  club-foot,  Polydactyly,  encephalocele  (Strassmann,  Ztschr. 
/.  Gcbnrtsh.  n.  Gynak.,  xxviii.  181,  1894),  hydrocephalus  and  scoliosis 
(Bonnaire,  Arch,  de  focol.,  xxi.  157,  1894),  sympodia,  spina  bifida,  and 
exomphalos  {Arch,  ili  ostct.  c  f/inec,  i.  41,  1894),  club-hand  and  various 
ankyloses  (E.  Apert,  Bull.  Soc.  anat.  etc  Par.,  5  s.,  ix.  767,  1895), 
absence  of  lower  jaw  and  external  ear  (A.  W.  Addinsell,  Trans.  Zand. 
Ohstct.  Soc,  xxxvii.  204,  1895),  etc.  etc.  The  only  malformation 
which  would  seem  to  he  more  conmon  in  oligohydramnion  than  in 
hydramnios  is  ankylosis  of  joints.  Further,  the  conditions  present 
resemblances  in  other  directions :  in  uniovular  twins,  one  fa'tus  (per- 
haps an  acardiac  one,  as  in  H.  Schiller's  case,  Ztschr.  f.  Gehurtsh.  n. 
Gynilk.,  xxxii.  200,  1895)  may  be  accompanied  by  deficiency  of  liquor 
amnii ;  the  condition  may  recur  several  times  in  the  same  patient 
(Mekerttschiantz,  Centrlbl.  f.  Gynuk.,  xi.  831,  1887) ;  and  there  is 
some  connection  between  oligohydramnion  and  amniotic  bands.  In 
all  these  directions  hydramnios  and  oligohydramnion  show  resem- 
blances. Many  interesting  questions  arise  out  of  the  study  of  the 
pathology  of  deficiency  of  the  liquor  amnii,  although  most  of  them 
belong  rather  to  the  pathology  of  the  embryo  than  to  that  of  the 
foetus ;  but  here  it  may  be  remarked  that  the  frequency  of  ankyloses 
and  of  club-foot  in  connection  with  oligohydramnion  would  seem  to 
support  the  view  that  these  states  are  sometimes  due  to  the  effects  of 
pressure  of  the  amniotic  mendjrane  permitted  by  the  al.isence  of  the 
fluid.  It  is  not  likely  that  this  anomaly  of  the  liquor  amnii  will 
enable  us  to  settle  the  question  of  the  source  of  the  fluid  {e.g.,  from 
the  foetal  kidneys) ;  for  although  absence  or  cystic  disease  of  these 
organs  may  occur  in  association  with  oligohydramnion,  they  may  also 
be  met  with  in  hydramnios. 


408  ANTKNATAI.    I'ATHOI.OdV    AM)    IIYCIKNE 

The  ]iatliiiliii^icul  (■liauges  in  tlie  placenta  and  nic'nil>i'anes  in 
oligoiiyilraniiiiiiii  liave  been  liltle  investigated.  The  plaeenta  lias 
heen  noted  to  lie  thick  and  inegular  in  form,  and  to  show  yellow  or 
grey  patches  and  even  caseous  nodules;  microscopically,  sclerosis  of 
both  the  maternal  and  the  f(etal  structures  has  been  found,  c.'/., 
endarteritis  oliliterans  and  periarteritis  (jf  the  vessels  of  the  villi. 
Manifestly  these  changes  cannot  be  regarded  as  special  to  oligo- 
hydramnion. 

The  symptomatology  of  oligohydramni(jn  is  not  well  known,  It 
may  be  noted  that  fo'tal  movements  are  unusually  distinct,  and  that 
they  may  be  very  painful.  Perhaps  the  obstetrician  may  observe 
that  the  tVetal  parts  are  unusually  ])alpable.  As  a  rule,  iiowever,  the 
diagnosis  of  deficiency  of  liquor  amnii  is  not  made  till  labour  is  in 
])rogress,  when  the  absence  of  a  marked  bag  of  membranes  and  of  the 
iluid  itself  will  reveal  it. 

There  are  other  morbid  states  of  the  fcetal  annexa  to  which  refer- 
ence might  here  be  made.  There  is,  for  instance,  myxomatous 
degeneration  of  the  chorionic  villi,  with  its  curious  occasional  sequel, 
deciduoma  malignum ;  there  are  the  various  pathological  states  of 
the  decidual  membranes  and  the  various  tyi)es  of  "  mole,"  fleshy  and 
sanguineous  ;  and  there  are  the  various  anomalies  and  malformations 
of  the  placenta  and  its  vessels  and  of  the  cord  and  its  vessels.  These, 
however,  are  morliid  conditions,  having  their  origin  anterior  to  the 
fretal  period  of  antenatal  life,  in  the  embryonic  or  germinal  epoch. 
They  will,  therefore,  lie  considered  with  the  pathology  of  the  embryo 
and  germ,  as  will  also  many  ])oints  touching  amniotic  bands  and 
pressure,  hydranniios,  and  oligohydramnicm,  which  have  been  only 
alluded  to  here. 

In  the  meantime,  let  it  be  again  repeated  and  constantly  borne  iu 
mind,  that  the  morbid  states  of  the  fo'tal  annexa  form  a  part,  and  an 
important  jiart,  of  f(etal  pathology ;  that  they  complicate  all  the 
questions  of  antenatal  pathogenesis ;  and  that  in  them  may  be  found 
an  answer  to  .some  at  least  of  the  problems  of  antenatal  disease  and 
deformity. 


CHAPTEE  XXIV 

Intrauterine  Death  of  the  Fu-tus  ;  Jleclianism,  Fu'tal  Asjjliyxia  and  Urtemia, 
liigor  Mmtis,  Clinical  History,  Syinptoniatology,  Physical  Examination, 
Diagnosis,  Pathology  of  Maceration,  etc.,  Abortion,  Causes  of  Firtal  Death, 
Treatment. 

Allusions  have  been  made  liere  and  there  throughout  this  work 
to  the  occurrence  of  ffetal  death,  and  it  will  have  been  gatliered  that 
most  of  the  morbid  states  which  have  been  described  may  be  the 
causes  of,  or  at  least  may  be  associated  with,  the  cessation  of  intra- 
uterine vitality ;  but  it  is  necessary  in  this  chapter  to  centralise  and 
elaborate  the  notions  upon  this  sitbject  which  will  have  been  formed. 
Its  discussion  is  suitably  placed  here,  for  it  demands  a  preliminary 
acquaintance  with  the  phenomena  of  fa?tal  pathology  and  with  the 
laws  which  govern  these  phenomena,  in  so  far,  of  course,  as  they 
are  known  to  us. 

To  the  patient  who  expects  to  become  the  mother  of  a  living 
iirfant,  as  well  as  to  her  medical  attendant,  the  occurrence  of  foetal 
death  brings  a  disappointment  which  has  a  sadness  and  a  vexation 
peculiarly  its  own.  Little  comfort  can  be  got  from  reflecting  that, 
from  the  forensic  point  of  view,  the  fu?tus  in  utero  cannot  have  died 
because  legally  it  was  never  ahve.  So  long  as  the  proof  of  live-birth 
requires  the  establishment  of  pulmonary  respiration  after  the  com- 
plete expulsion  of  the  infant  from  the  maternal  passages,  so  long  will 
it  be  possible  to  deceive  one's  self  as  to  the  value  of  fwtal  life ;  but  the 
mother  of  a  dead  fit'tus  does  not  really  deceive  herself  on  this  matter, 
and  her  medical  attendant  feels  no  less  acutely  the  opprobrium  on 
his  art  that  the  unborn  infant  should  not  come  living  to  the  birth. 
Death  before  (legal)  life  may  be  a  paradox ;  but  death  before  birth  is 
a  very  sad  certainty.  When,  further,  the  antenatal  death  is  repeated 
ill  successive  pregnancies, — when,  so  to  say,  there  is  habitual  fuetal 
death, — the  maternal  disappointment  mounts  up  to  complete  dis- 
couragement and  anguish,  and  the  obstetrician  feels  acutely  his 
helplessness  under  the  most  trying  circumstances.  A  reproductive 
life  history  which  is  a  record  of  dead  births  is  an  appalling  cata- 
strophe, look  at  it  as  we  may.  I  have  recently  interviewed  a  woman 
who  has  had  six  dead-born  fwtuses  between  the  sixth  and  seventh 
month  of  pregnancy,  and  one  eighth-month  infant  that  only  lived  a 
few  hours;  she  had  seen  several  doctors  and  had  taken  much 
medicine,  but  had  never  brought  an  infant  to  the  full  time,  and  had 
only  once  given  birth  to  a  child  living  at  the  time  of  labour.  A  very 
careful  examination  of  the  case  revealed  no  apparent  cause  for  this 
reproductive  failure  ;  but  one  cannot  put  the  matter  aside  and  content 
one's  self  with  the  reflection  that  there  is  no  evident  cause,  and  that  the 


410  ANTKNATAL    I'ATMOLOCY   AM)    inCIKNK 

patient  .siiiiply  has  "  the  Iialtit  of  giving  birtli  tn  ik'ad  ljal>iL's."  The 
niotlior  liLTself  IVx'ls  that  tlicie  is  sdincthini,'  very  iniiiuifect  in  the 
ol)stetric  ait  and  si'ience  wliich  canmit  liclp  her  to  hiing  a  living 
infant  to  the  light:  whe  knows  that  tinn^  after  time  the  fotiis  was 
alive  till  a  week  or  a  fortniglit  l)efore  its  eximlsion  from  the  uterus; 
she  took  every  eare  of  herself,  and  she  swallowed  faithfully  all  the 
medicine  that  was  given  her;  and  yet  time  after  time  she  noticed 
that  the  ftetal  movements  ceased ;  she  waited  in  sickening  dread  for 
some  days,  and  again  gave  birth  to  a  macerated  fo'tus.  The  medical 
profession  cannot  he  content  to  leave  uninvestigated  this  prul)lem  of 
reciuTcnt  or  "  habitual  "  fn'tal  death  ;  humanitariau  as  well  as  economic 
necessities  impel  us. 

lleference  is  not  here  made  to  the  subject  of  intranatal  death, 
although  it  also  has  a  sadness  quite  its  own.  To  see  a  child,  large, 
strong,  well  nourished,  and  free  from  disease  or  deformity,  ])erish 
during  its  transit  through  tiie  birth  canals  by  reason  of  great  dispro- 
portion between  the  size  of  the  pelvis  and  the  head  of  the  infant,  or 
on  account  of  one  or  other  of  the  many  dangerous  complications  of 
labour,  is  indeed  a  .sad  spectacle.  AVhen  this  death  is  apjiarcntly  due 
to  nothing  save  a  somewhat  unusual  degree  of  betal  development,  and 
to  an  advanced  state  of  ossification  of  the  cranial  bones  (as  in  a  case 
(152)  which  I  saw  with  Dr.  A.  T.  Sloan  in  189;J,  and  in  which  four 
pregnancies  ended  in  the  e.xpulsion  of  infants  still-l)f(rn  from  the 
above  causes),  there  is  a  peculiar  element  of  vexatious  disajiiwintment 
in  the  occurrence.  To  see  the  infant  pass  "from  the  f(et>is-sluml)er 
into  the  sleep  of  death,  out  of  the  amnios-skin  of  this  w^orld  into  the 
shroud,  the  amnios-skin  of  the  next"'  is  to  the  obstetrician  who  sets 
a  high  value  on  infantile  life  both  a  humiliation  and  a  reproach. 
When  the  mother  also  dies  in  labour  with  her  child,  there  is  produced 
a  situation  which  touches  every  heart,  and  a  calamity  which  calls 
forth  universal  sympathy.  ]Milton's  touching  lines  in  his  "  Ki)itaiih  on 
the  Marchioness  of  Winchester  "  might  well  serve  for  many  a  humlilcr 
mother  thus  bereft  of  maternity  and  life  at  one  blow : 

"  Ami  now  with  second  liope  she  goes 
And  ciills  Lucina  to  her  throes  ; 
But  whether  by  mischance  or  hhinie 
Atropo.';  for  Lucina  came  ; 
And  with  remor.'selcss  cruelty 
Sjioil'd  at  once  hotli  fruit  and  tree  ; 
The  ]iM]iU'.ss  liaUc  before  his  birth 
Had  burial,  vet  not  laid  in  earth, 
And  tlic  lani;ui.'<h'(l  mother's  wondi 
\\'(is  iKil  lonj;  a  living  tondi." 

But  even  in  the  worst  cases  of  intranatal  death  there  is  not  the  same 
feeling  of  helples.sness  which  is  exiierienced  in  dealing  with  antenatal 
death.  Every  year  marks  new  advances  in  the  management  of  child- 
birth and  in  tlie  ])revention  of  accidents  to  the  foetus  in  the  maternal 
passages ;  the  limitation  of  the  destructive  methods  of  delivery 
(embryulcia,  craniotomy)  liecomes  ever  more  sharply  insisted  upon ; 

'  Kichtcr  s  FImcci;  Fruit,  and  Thorn  I'lWrs.     Noel'.s  Traiisl.,  i.  ;!2S,  1871. 


<l 


FCF.TAL   ASPHYXIA  411 

and  the  obstetrician  looks  hopefully  forward  to  a  not  very  distant 
time  when  it  will  lie  possible,  without  increasing  the  risks  to  tiie 
mother,  to  give  every  chance  to  the  cliild.  But  about  antenatal^ 
deatli  the  same  cannot  yet  be  said ;  the  problem  of  the  prevention  of 
intrauterine  mortality  is  much  more  difficult  and  much  moie  com- 
plicated ;  there  are  some  few  hopeful  signs,  Init  as  yet  they  are  very 
far  off.  Principiis  obsta,  check  the  Ijeginnings,  must  be  the  thera- 
peutic watchword  !     But  how  ? 

Mechanism  of  Foetal   Death  :    FcEtal  Asphyxia. 

When  it  is  remembered  that  the  life  of  the  foetus  is  of  a  semi- 
parasitic  kind,  it  will  be  readily  granted  that  the  explanation  of  the 
mechanism  of  its  death  becomes  not  a  little  difficult.  There  are 
causes  of  death  which  will  act  upon  the  unborn  infant  from  beyond 
the  placental  liarriers,  and  there  are  causes  which  may  arise  in  the 
foetus  itself  either  as  a  result  of  the  action  of  the  maternal  causes  or 
possibly  independently  of  them.  In  the  ^'ast  majority  of  the  cases 
of  foetal  death,  the  cessation  of  vitality  is  no  doubt  due  essentially  to 
causes  which  develop  in  the  fcetal  organism,  however  closely  these 
may  be  associated  with  extrauterine  morbid  states ;  the  fcptus  dies  of 
auto-intoxication  ;  it  is  poisoned  by  the  piroducts  of  its  own  metabolism. 
Doubtless  there  are  several  kinds  of  fcetal  auto-intoxication,  but 
little  is  known  with  regard  to  any  of  them  save  foetal  asphyxia. 
Fa'tal  uramia  may  occasionally  occur,  but  next  to  nothing  is  known 
regarding  it.  Palazzi  {Ann.  ili  ostet.  e  r/inec,  xxiii.  225,  1901)  has 
pointed  out  that  when  through  placental  inadequacy  there  is  a  risk 
of  urtemia,  there  is  also  a  possiliility  that  the  kidneys  may  vicariously 
assist  in  the  elimination  of  the  eft'ete  products ;  while  in  the  case  of 
faHal  asphyxia  there  is  no  foetal  organ  which  can  take  ou  tlie  function 
of  the  gaseous  interchange  when  the  placenta  fails.  It  may  also 
be  supposed  that  poisons  and  toxins  passing  from  the  mother  to  the 
foetus  kill  the  latter  by  their  direct  ettect  upon  its  tissues ;  but  it  is 
more  probable  that  they  prove  fatal  by  their  action  upon  the 
placenta,  which,  becoming  inadequate,  gives  rise  to  foital  asphyxia.  A 
marked  and  especially  a  sudden  rise  in  the  maternal  temperature 
may  kill  the  foetus  in  utero ;  it  is  supposed  that  the  mechanism  here 
is  degeneration  of  the  myocardium  of  the  fretus  on  account  of  the 
high  temperature,  l^ut  even  in  this  case  asphyxia  may  be  invoked  as 
a  link  in  the  chain  of  lethal  factors.  It  may  then  be  asstimed  that 
f(etal  asphyxia  is  the  great  immediate  cause  of  fo'tal  death.  The 
various  conditions  which  may  iiroduce  this  state  of  the  fu'tus  will  be 
referred  to  later ;  in  tiie  meantime  the  mode  in  which  the  asphyxia 
brings  about  the  intrauterine  death  must  be  described. 

Fcotal  asphyxia  may  be  acute  or  chronic ;  the  former  variety  is 
due  to  causes  which  rapidly  and  completely  throw  the  placental 
system  out  of  action,  and  the  latter  to  a  more  slowly  produced  or  a 
less  complete  interruption  of  the  fo'to-maternal  interclianges.  During 
labour  (especially  after  the  rupture  of  the  membranes)  new  factors 
come  into  play,  but  the  result  is  practically  the  same  as  in  pregnancy. 


412  ANTENATAL   PATHOLOGY   AND   HYGIENE 

Carbonic  acid  ami  other  waste  jmjdiicts  aceuumlate  in  the  foetus,  and 
oxyt^eu  is  not  suj^ilied  to  it. 

In  the  acute  tyi)e  of  fo'tal  asphyxia,  it  may  he  supposed  that  tlie 
carhonif-  acid  in  the  l)lood  first  excites  the  vaf^us,  wliicii  causes  slowing 
of  the  rate  of  the  f(vtal  iieart  and  irregularity.  Then,  the  vagus 
becomes  paralysed,  the  heart's  action  is  quickened ;  and  finally  it 
stops  from  paralysis  of  the  sympathetic  nerves.  Meanwhile  the 
respiratory  centres  will  also  liave  been  excited,  attempts  will  have 
been  made  to  inspire,  the  liquor  amnii  will  have  been  sucked  into 
the  lungs,  and,  through  tlie  congestion  of  tiie  pulmonary  capillaries 
thus  produced,  tlie  lilood  pressure  in  the  aoita  and  its  Iiranches 
(including  the  uml)ilical  arteries)  will  fall.  No  doubt  the  ])rocess  is 
more  complex  than  has  been  stated  above;  but  tlie  two  factors  which 
have  been  descriljed  lead  at  any  rate  by  their  combined  action  to  the 
death  of  tlie  foetus.  In  the  more  chronic  form,  it  is  believed  that 
inspiratory  efforts  are  not  usually  made,  the  increasingly  venous 
cliaracter  of  the  blood  slowly  diminishing  tiie  excitability  of  the 
respiratory  centres  in  the  medulla,  so  that  neitlier  the  absence  of 
oxygen  nor  the  presence  of  carbonic  acid  stimulate  them.  In  both 
types  the  heart  finally  ceases  to  contract,  and  the  fa>tus  presumably 
is  dead.  A  difficult  question,  however,  here  arises.  It  is  possible 
that  the  cause  of  tlie  foetal  asphyxia  may  be  suddenly  removed  just 
after  the  lieart  has  ceased  beating ;  under  these  circumstances,  will 
tlie  cardiac  contractions  recommence,  and  if  so,  after  what  jieriod  of 
cardiac  inactivity  will  they  so  recommence  ?  It  is  here  that  the 
semi-parasitism  of  the  fietus  comes  into  play  and  complicates  the 
problem.  I  think  it  is  quite  possible  that  the  heart  may  cease  beat- 
ing for  a  considerable  number  of  minutes,  and  recommence  again  if 
the  cause  of  the  asphyxia  be  removed.  Certain  facts  which  were 
pointed  out  in  Chapter  IX.  (p.  134,  et  scq.)  must  here  be  kept  in 
mind :  they  were  the  degree  of  the  automatic  activity  of  the  fcctal 
heart  and  its  less  immediate  dependence  upon  an  oxygenated  state  of 
the  blood  circulating  through  it.  From  these  characters  of  fo?tal 
cardiac  action  it  might  be  permissible  to  conclude  that  fo'tal  death 
would  generally  be  establislied  very  slowly.  On  the  other  hand, 
there  is  the  well-known  fact  that  in  maternal  death  Ca-sarean  section 
must  be  performed  very  (juickly  if  the  fcetus  is  to  be  saved.  In  the 
latter  case,  however,  the  maternal  part  of  the  placenta  is  dead,  while 
in  the  former  it  is  alive  ;  further,  in  tlie  latter  case  the  attempt  is 
made  to  excite  cardiac  action  by  setting  up  extrauterine  (pulmonary) 
respiration,  probably  a  more  difficult  matter  than  to  re-excite  cardiac 
action  by  removing  the  obstacles  to  placental  respiration.  On 
account  of  tliese  facts,  and  by  reason  of  the  difficulties  of  antenatal 
diagnosis,  it  becomes  a  very  difficult  problem  to  give  an  opinion  as  to 
the  death  of  the  fa'tus  in  utero.  To  this  matter,  however,  I  shall 
return  immediately. 

The  immediate  results  of  fatal  fo'tal  asjihyxia  are  not  often  to  be 
observed  save  in  connection  with  intranatal  death,  and,  as  wt'  have 
seen,  true  fietal  deatli  dilfers  somewhat  from  that.  So  far,  however, 
as  is  known,  tliey  consist  in  the  presence  in  the  vessels  of  a  very 


FCETAL   RIGOR   MORTIS  413 

dark  coloured  blood,  eitlier  with  no  clots  or  with  a  few  dense  clots 
in  it ;  in  the  occurrence  of  ecchynioses  on  tlie  large  vessels  of  the 
thorax  and  in  tlie  subpleural  and  suljpericardial  tissues,  and  some- 
times of  small  intracranial  and  pulmonary  hannorrhages ;  in  the 
finding  of  liquor  amuii  and  meconium  in  the  air  passages ;  and  in 
the  transitory  appearance  of  rigor  mortis.  There  may  be  other  signs 
noted,  but  it  is  doulitful  how  far  they  are  to  be  regarded  as  due  to 
the  traumatism  of  labour.  The  advanced  post-mortem  changes 
(c.ff.  maceration)  are  referred  to  immediately.  The  changes  which 
have  been  mentioned  above  are  evidently  due  to  tlie  chemical 
changes  in  the  blood  and  to  the  [)rematnre  attempts  at  respiration. 
What  the  alterations  are  in  the  other  modes  of  foetal  death  (e.i/. 
ura?mia  ?)  we  do  not  rightly  know ;  it  has  lieen  stated  that  degenerat- 
ive changes  in  the  myocardium  characterise  the  lethal  effect  of  a 
high  temperature,  but  the  evidence  is  slight. 

Antenatal  Eigok  Mortis. 

Eigor  mortis  in  the  foetus  lias  been  mentioned  above.  I  have 
abeady  referred  to  its  occurrence  on  p.  178  of  this  work,  and  also  in 
a  special  article  (80)  in  Teratologia ;  but  I  may  summarise  my  chief 
conclusions  here,  for  they  are  of  some  importance.  I  have  seen 
several  instances  of  antenatal  rigor  mortis,  including  the  one  described 
in  the  above  article.  It  was  a  case  which  occurred  in  the  practice  of 
Dr.  D.  Milligan.  The  child's  heart  did  not  beat  at  birth,  nor  was  there 
any  pulsation  in  the  cord  during  delivery.  The  head  presented,  and 
the  labour  lasted  from  four  to  five  hours.  The  left  arm  was  sharply 
and  firmly  flexed,  and  there  was  a  similar,  but  less  noticeable, 
condition  of  the  right  knee.  Two  hours  after  birth  I  saw  the  infant, 
when  there  was  still  some  stiffness;  but  soon  this  entirely  dis- 
appeai-ed.  The  foetus,  a  male,  weighed  1220  grms.,  had  a  length  of 
40  cms.,  and  the  appearance  of  a  fcetus  of  about  six  and  a  half 
months ;  the  pupillary  membrane  was  still  present.  A  large  and 
comparatively  recent  black  blood-clot  was  found  in  the  placenta,  on 
the  maternal  surface.  I  believe  that  in  tliis  case  the  rigor  mortis  was 
passing  off  when  the  fcetus  was  expelled. 

The  first  recorded  case  of  antenatal  rigor  mortis  seems  to  have 
been  that  of  Chowne  {Lancet,  \h  199,  ii.  for  1840-1),  yet  Casper  in 
his  Forensic  Medicine  (New  Sydenham  Soc.  Transl.,  i.  29,  1861) 
writes :  "  I  have  never  observed  cadaveric  stiffening  in  the  im- 
mature foetus,  .  .  .  even  in  the  case  of  mature  new-born  infants  and 
little  children  it  is  feeble  and  transitory."  Further  instances,  how- 
ever, were  soon  reported  by  Schultze  {Deutsche  Klinik,  No.  41,  1857), 
by  Curtze  {Ztschr.  f.  Med.  Chir.  u.  Gchurtsh.,  261,  1866),  by  G. 
Tourdes,  in  twins  (article  "  Cadavre "  in  Diet.  encyclo2i.  d.  sc.  med., 
1  s.,  xi.  420,  1870),  by  W.  C.  Grigg  {Brit.  Med.  Journ.,  ii.  for  1874, 
pp.  493,  586,  707),  J.  A.  Thompson  {ibid.,  ii.  for  1874,  pp.  550,  640, 
772),  P.  A.  Young  {iiid.,  ii.  for  1874,  p.  707),  C.  H.  W.  Parkinson 
{ibid.,  ii.  for  1874,  p.  772),  by  M.  Bailly,  in  twins  {Arch,  de  tocoL,  iii. 
641,  1876),  by  A.  Martin  {Ztschr.  f.  Gchurtsh.  u.  Gyndk,i.  55,  1877), 


414  ANIKNATAI,    I'A  I  1 1(  )|.(  )(.V    AM)    IIVCIKNK 

liy  I..  W.  lluUi'v  (J)lssni.,  Maibui-i,',  188U),  hy  K  lJa|,'in(/()Uil  (Tliisr, 
r'aris,  1S8U),  by  K.  lioxall  {Lancrf,  ii.  for  1884,  p.  GO),  hy  15. -loiifs 
{BriL  Med.  Jo  urn.,  ii.  for  1885,  p.  9G3),  hy  T.  David.soii  (ihuL,  i.  for 
188(),  ]i.  12),  hy  Stui)ii)f  (Arch./.  Gijnack.,  xxviii.  472,  188G),  hv 
.Saii>,a"r  (jhiil..  xxviii.  47:!,  188G),  by  Dolirii  (Cnitrlhl.  f.  (iynak.,  x.  1 1:'.. 
188G),  hy  U.  Keis  {Arch.  f.  Gynaek.,  xlvi.  384,  1894),  hy  M.  Laii-c 
{CentrlU.  f.  Gyndk. ,  x\ii\.  1217,  1894),  by  N.  S.  Kaiuiegisera  {Joum. 
akoush.  i  jensk.  boliez.,  ix.  ol,  1895),  by  Steiuhiicliel  (Wicu.  imil. 
Wchnsrhr.,  xlv.  370,  434,  474,  1895),  by  B.  Jones  {Lamcl,  ii.  for  1895, 
]).  1020),  and  by  Knorr  (Cen/rlbl.  f.  Gyndk.,xx.  40,  1896).  In  several 
of  these  eases,  the  dead  and  rigid  infant  was  removed  from  the  uterus 
by  Ciesarean  section,  i)roving  conehisively  that  rigur  mortis  may 
occur  in  the  uterine  cavity.  In  most  of  the  cases  the  labours  were 
alinormal  (placenta  pi'icvia,  accidental  haauoirhage,  eclampsia,  pelvic 
contraction,  etc.),  and  the  fo-tal  death  must  he  ascrilied  thereto ; 
proljaldy  the  rigor  mortis  which  follows  death  before  labour  has  com- 
menced will  seldom,  if  ever,  be  seen,  unless  indeed  delivery  occur 
very  ra])idly  and  very  soon  thereafter. 

The  rigidity  in  some  of  the  reported  cases  was  well  marked  and 
widespread;  practically,  it  always  alfected  tlie  limbs  and  generally 
also  the  muscles  of  the  jaws  and  neck.     It  jiassed  oil'  in  times  varying 
from   one  hour  to  thirty   hours  after   birth,  and    the  post-mortem 
examination  usually  revealed  simply  the  signs  of  premature  respira- 
tion.   There  is  nothing  in  the  intrauterine  environment  to  prevent  the  j 
occurrence  of  rigor  mortis  ;  and  J.  Tissot  {Arch,  phyaiol.  norm,  ct  path.,  i 
5  s.,  vi.  860,  1894)  has  shown  that  it  takes  place  in  fietal  kittens; 
possibly  it  may  be  slightly  marked,  and  may  come  on  sooner  and  pass 
ott' earlier  than  in  postnatal  death,  but  even  of  these  dill'erences  tliere  ( 
is  not  much  proof.     Of  course  every  case  of  congenital  rigidity  is  not 
necessarily  an  instance  of  rigor  mortis  {e.cj.  Gibb's  case.  Lancet,  ii.  for 
1858,  p.  497).     The  rarity  with  which  it  has  been  observed,  or  at  any 
rate  recorded,  may  be  explained  by  several  circumstances :  the  non- 
coincidence    of   fcetal   death    and    expulsion  from    the    uterus,   the  : 
absorption    of   the    obstetrician    in    liis   duties    to    the   mother,   the 
characters  of  foetal  rigor  mortis,  and  perhaps  the  use  of  the  Schultze  ! 
swinging  movements  in  attempted  resuscitation.      Nevertheless  the  ' 
proof  of  the  occurrence  of  antenatal  cadaveric  rigidity  is,  I  think,  i 
complete,  at    least    in    the    cases   where   death   occurs    during  or  > 
immediately  before  the  supervention  of  labour  pains ;  iiud  it  may  be  : 
met  with  in  immature  as  well  as  in  mature  ftetuses.     lV)ssil>ly,  in 
cases   of   ftntal  death    occurring   slowly   in   utero   from    c;iuses   not  ■ 
associated  with  delivery,  the  gradually  ceasing  fietal  circulation  and  i 
the  long-drawn-out  manner  in  wiiich  vitality  disappears  may  impresB 
special  cliaracters  on  the  rigor  nuntis  which  then  supervenes. 

Clinical  History  and  Symptomatology  of  FcEtal  Death. 

In  cases  of  tVetal  death,  it  is  not  unconnnon  to  be  able  to  elicit  ' 
the   history  of  the  previous  occurrence  of  the  same  fatality  in  the 
mother's  i-c]irodiu'tive  record.     When  this  so-called  "  habit  of  giving 


i 


I'd'/I'AL   DEATH  415 

birth  to  ilead  infants"  is  met  with  in  any  case,  it  is  coiiimou  to  liiid 
inilieations  of  some  distinct  maternal  disease.  For  instance,  there 
may  be  the  history  of  syphilitic  manifestations  ([ip.  246,  254),  anrl 
according  to  some  authorities  the  "  habitual "  fu^tal  death  may  itself 
be  the  manifestation  and  the  sole  manifestation  of  that  disease.  But 
there  may,  in  other  instances,  be  a  record  of  long  continued  ana-mia, 
of  malaria,  of  alcoholism,  of  lead  poisoning,  of  heart  disease,  or  of 
renal  disease  with  albuminuria ;  again,  it  may  be  gathered  that  the 
mother  had  for  a  long  time  suffered  from  endometritis,  or  uterine 
displacement,  or  disease  of  the  placenta.  Home  of  tlie  conditions 
which  have  been  named  may  be  dependent  upon  each  other,  as  for 
example  placental  alterations  upon  maternal  albuminuria.  Finally, 
in  some  instances,  there  may  be  no  very  evident  cause  for  the 
recurring  fu^tal  deaths  either  in  the  mother  or  in  the  father.  Very 
curious  cases  are  those  in'  which  every  alternate  pregnancy  ended  in 
the  birth  of  a  dead  hptus,  or  in  which  all  the  infants  of  one  sex  were 
born  dead  and  all  those  of  the  other  alive. 

When  the  past  history  of  the  mother  yields  no  information  which 
has  any  obvious  bearing  on  the  death  of  the  unborn  infant,  the  record 
of  the  present  pregnancy  ma\'  do  so.  Thus  the  mother  may  have 
been  the  subject  of  a  serious  traumatism,  or  have  been  the  prey  of 
violent  emotion,  although  it  must  be  at  once  admitted  that  not  in- 
frequently even  very  serious  accidents,  and  very  considerable  per- 
turbations, may  be  followed  by  the  birth  of  a  healthy  living  infant 
at  the  full  term.  Again,  the  mother  may  have  suffered  from  an  acute 
illness  in  her  pregnancy,  such  as  pneumonia,  cholera,  or  smallpox  ; 
or  she  may  have  become  infected  with  syphilis,  or  have  de\'eloped 
cardiac  or  renal  disease.  Yet  again,  there  may  have  been  no  acci- 
dent or  disease  during  gestation  to  give  an  indication  of  the  possible 
condition  of  the  fretus;  when  a  dead  foetus  is  born  after  such  a 
pregnancy,  we  are  led  to  infer  that  the  death  must  be  due  to  condi- 
tions arising  in  utero,  in  the  placenta  or  fcetus,  independent  of  the 
maternal  health.  These  cases  present  most  puzzling  problems ;  and 
for  most  of  them  no  hypothetical  explanation  even  is  forthcoming. 
Of  course,  I  do  not  here  refer  to  instances  of  intranatal  death  due 
to  the  many  lethal  influences  which  may  then  come  into  play. 

The  symptomatology  of  ftetal  death  abounds  in  phenomena  which 
suggest  the  possibility,  or  even  the  probability,  of  the  occurrence  of 
this  disaster,  but  is  lacking  entirely  in  positive  indications  thereof. 
When  it  is  borne  in  mind  that  the  symptoms  of  intrauterine  death 
are  in  great  measure  the  negation  of  the  symptoms  of  pregnancy, 
their  indefinite  character  will  be  appreciated.  Further,  since  preg- 
nancy may  cause  no  symptoms  which  can  be  regarded  as  absolutely 
diagnostic,  so  fcetal  death,  in  a  still  more  marked  degree,  may  yield 
no  certain  indications.  The  mother  may  fear  that  her  infant  is 
dead ;  her  fears  may  be  justified,  but,  on  the  other  hand,  they  may 
not.  All  obstetricians  must  have  met  with  cases  in  which  they  were 
assured  by  anxious  pregnant  women  that  the  child  in  the  womb 
was  dead,  and  yet  at  the  full  term  a  living  and  healthy  infant  was 
born.     At  the  same  time  there  are  some  symptoms  of  fLutal  death 


416  ANTRN'ATAI,    I'A  rH()I.()(;V    AND    HYdlF.NK 

which  liavo  a  certain  ilcijree  <if  diai^nostio  vahiu  and  iniportance. 
They  arc  of  1,'reater  vahie  if  tiiey  supinveue  iijioii  well-marked 
syinptiiiiis  (if  ])regnaiu'y.  They  coiisisl,  in  the  first  ])lare,  in  various 
ill-defined  feelings  of  the  mother,  such  as  headache,  loss  of  appetite, 
sensations  of  heat  and  cold,  tinnitus  aurium,  general  malaise,  epi- 
gastric ]min,  a  feeling  of  weight  in  the  abdomen,  and  rectal  and 
vesical  uneasiness.  In  the  second  place,  there  may  occur  a  profuse 
p(!rspiration  or  a  sudden  diarrhtea,  and  there  may  be  reason  to 
believe  that  this  symptom  was  synchrijiious  with  tlie  death  of  the 
infant.  In  the  third  ]ilace,  there  is  the  ilisap])earance  of  various 
symptoms  of  pregnancy,  such  as  morning  sickness,  special  tyjies  of 
neuralgia,  salivation,  and  the  like.  In  the  fourth  place,  there  is  the 
cessation  of  foetal  movements,  and,  if  these  movements  have 
pi'eviously  been  clearly  recognised  by  the  patient,  it  cannot  be  denied 
that  this  symptom,  negative  although  it  is,  lias  a  very  considerable 
value.  Further,  its  value  is  increased  if  the  cessation  has  followed 
upon  a  series  of  very  violent  and  disorderly  movements,  more 
especially  if  these  in  their  turn  have  been  preceded  by  some  recog- 
nisable cause  of  fcetal  death,  such  as  a  severe  blow  on  the  abdomen, 
a  sudden  emotion,  etc.  It  need  not,  at  the  same  time,  be  pointed 
out  that  for  the  purpose  of  diagnosis  this  symptom  may  be  vei'v 
fallacious,  for  there  are  times  when  the  foetus  is  quiescent,  and 
conditions  under  which  the  active  fcetal  movements  cjinnot  be  dis- 
tinguished ;  again,  the  patient  may  have  made  a  mistake  in  thinking 
that  she  felt  quickening  at  all,  and  so  also  her  ojiinion  that  quicken- 
ing had  ceased  may  be  erroneous.  Sometimes  a  sensation  of  passive 
fcetal  movements  has  been  described  by  women  carrying  a  dead 
foetus,  movements  elicited  by  sudden  changes  in  position  ;  liut  the 
value  of  this  symptom  is  problematical.  Finally,  there  are  the 
indications  of  the  death  of  the  fo-tus  derived  from  the  retrogression 
of  the  mammary  changes ;  the  woman  may  note  that  the  glands  are 
not  so  tender  and  have  not  the  swollen  feeling  which  they  had,  and 
that  these  changes  have  succeeded  a  time  when  the  tenseness  and 
sensitiveness  were  greatly  increased. 

All  these  symptoms  have  a  greatly  augmented  importance  and . 
diagnostic    value   when    the    patient   has  in  one  or  more   previous 
pregnancies  experienced    similar  sensations,  and    has  found  mit   by 
sad  demonstration  that  they  meant  intrauterine  death. 

Diagnosis  of  Fcetal  Death. 

It  is  doubtful  whether  the  antenatal  diagnosis  of  fu?tal  ilealh  can 
ever  be  made  with  alisolute  security ;  it  can  never  be  affirmed  with 
the  same  certainty  as  one  affirms  the  presence  of  fcetal  life  after  hear- 
ing the  fci'tal  heart :  but  a  very  strong  ])rovisional  diagnosis  can  be 
formed.  This  provisional  opinion  is  founded  upon  th(>  jiast  history 
of  the  patient,  the  consideration  of  her  symptoms,  and  the  physical 
examination  which  the  obstetrician  makes.  To  the  past  clinical 
history  and  to  the  symi)tonuitology  I  have  already  referred  :  I  must 
now  consider  in  detail  the  physical  examination. 


F(ETAL   DEATH  417 

In  the  first  place,  the  inspection  and  palpation  of  the  niamniary 
glands  may  yield  indications  of  the  death  of  the  fcetus.  Intrauterine 
death  would  seem  to  have  the  same  effect  upon  the  mamniie  as  the 
birth  of  the  cliild,  but  this  primary  effect  soon  passes  off.  At  first 
the  glands  show  increased  sweUing  and  tenderness,  the  cutaneous 
veins  become  more  evident,  and  the  secretion  first  of  colostrum  and 
later  of  true  milk  becomes  acti\'e.  In  a  few  days,  however,  these 
phenomena  pass  off",  and  the  glands  gradually  pass  into  a  quiescent 
state.  When,  ultimately,  the  dead  ftptus  is  expelled  from  the  uterus, 
it  has  been  noticed  that  the  usual  mammary  engorgement  which 
follows  birth  is  wanting.  E.  Tridondani  (Ann.  di  ostet.  c  gincc,  xxi. 
71,  1899)  draws  special  attention  to  the  value  of  these  mammary 
changes,  and  indicates  that  perhaps  in  the  microscopical  and  chemical 
characters  of  the  milk  may  be  found  additional  indications  of  the 
death  of  the  foetus  (disappearance  of  colostrum  corpuscles,  diminution 
in  the  amount  of  sugar  and  fat,  etc.). 

In  the  second  place,  the  careful  examination  of  the  abdomen  has 
a  very  considerable  diagnostic  value  by  reason  of  the  change  in  the 
physical  signs  there  apparent.  The  abdomen  ceases  to  have  the 
appearances  corresponding  to  the  ascertained  or  estimated  date  of 
pregnancy :  it  seems,  and  probably  is  really,  smaller  than  it  was ;  it 
loses  the  marked  globular  projection  in  the  middle  line,  and  becomes 
more  expanded  in  the  flanks,  suggesting  ascites ;  the  uml  lilicus  is  no 
longer  projecting ;  there  is  absence  of  the  firmness  and  resistance  of 
the  uterus  containing  a  living  foBtus,  in  fact,  it  becomes  difficult  to 
map  out  the  uterus  by  palpation  at  all ;  no  muscular  contractions  can 
be  felt  sweeping  over  its  surface  ;  and  the  whole  uterus  on  account  of 
its  flaccidity  tends  to  sink  into  the  pelvic  brim  and  to  lose  its  normal 
shape  and  relations.  The  pigmentary  and  vascular  developments  in 
the  abdominal  walls  undergo  involution,  and  it  may  be  added  here 
that  the  \'ulvar  and  vaginal  dusky  red  discoloration  (Jacquemier's 
sign  of  pregnancy)  gradually  disappears.  When  the  attempt  is  made 
to  map  out  the  various  parts  of  the  foetus,  it  usually  fails,  at  any  rate 
when  intrauterine  death  has  taken  place  a  week  or  more  previously. 
The  hard  glolie  of  the  head  cannot  be  detected,  and  there  is  a  general 
loss  of  the  feeling  of  resistance  in  the  fcetal  tissues,  so  that  the  dead 
infant  is  more  or  less  completely  moulded  to  the  containing  uterus. 
A  special  sensation  of  crackling  (scroscio),  due  to  the  looseness  of  the 
bones  of  the  head,  has  been  described  by  Negri  (Ann.  di  ostet.  c  qincc., 
V.  82,  1883 ;  vii.  223,  1885).  The  head  often  ceases  to  be  the  pre- 
senting part.  The  most  careful  palpation  fails  to  elicit  active  foetal 
movements,  and  no  foetal  heart  is  heard  on  auscultation ;  but  these 
negative  signs  have,  of  course,  only  a  limited  value  in  forming  a 
diagnosis,  for  over  and  over  again  a  living  infant  has  been  born,  and 
yet  the  obstetrician  had  neither  heard  its  heart  nor  felt  its  move- 
ments after  the  most  rigorous  examination.  The  uterine  souffle  may 
be  heard  after  the  death  of  the  foetus,  but  it  has  been  stated  that  its 
quality  is  changed.  Apparently  it  has  little  value  as  a  sign  of  foetal 
death,  and  the  same  remark  applies  to  the  sounds  due  to  intrauterine 
decomposition  which  have  been  referred  to  by  some  authors.  In  the 
27 


418  ANTIA  Al'AI.    I'M  IIOI.lX.'i     AND    IIYCIKNE 

rare  cases,  however,  in  which  antenatal  jnitrefaetion  is  set  up  (usually 
after  rupture  of  the  monibranes),  the  accumulation  of  gases  leads  to 
the  development  of  a  tympanitic  note  on  percussion  over  the  uterus. 

In  the  tliird  place,  the  vaginal  and  bimanual  examinations  may 
bring  out  a  few  additional  facts  (of  no  great  diagnostic  value)  re- 
garding ftetal  death.  If  the  death  has  been  recent,  no  appreciable 
diiferences  may  be  detected ;  l)ut  if  it  has  taken  place  ten  or  fourteen 
days  previously,  it  may  be  found  that  tlie  cervix  and  lower  uterine 
segment  have  already  lost  the  softness  jjcculiar  to  pregnancy  with  a 
living  foetus,  and  that  the  pulsating  artery  in  the  anterior  fornix  is 
no  longer  to  be  easily  felt.  It  will  be  dillicult  to  distinguish  the 
presenting  part.  Sometimes  it  may  bt;  found  that  a  fluid  is  dis- 
charged at  intervals  of  time  from  the  uterus ;  it  may  be  clear  like 
serum  or  it  may  l)e  blood-stained,  or  liave  a  dirty  brownish  colour. 
This  escape  of  fluid  (Injdrorrluea  (jracidaruin)  has  sometimes  been 
associated  with  fo'tal  death.  It  must,  however,  l^e  borne  in  mind 
that  it  may  occur  with  a  living  child  also ;  it  has,  for  instance,  been 
noted  in  those  curious  cases  in  which  the  membranes  rupture  in  utero 
and  the  fcetus  goes  on  developing  outside  them  in  an  extra-anmiotic 
or  extra-membranous  fashion,  as  in  K.  lieifi'erscheid's  observation 
{Centrlhl.f.  Gi/ndk.,  x\\:  1143,  IDOl).  On  the  supposition  that  the 
intrauterine  temperature  falls  after  firtal  death,  it  has  been  proposed 
to  introduce  a  thermometer  between  the  uterine  walls  and  the  mem- 
branes for  the  purposes  of  diagnosis ;  but  the  procedure  cannot  lie 
commended. 

In  the  fourth  place,  the  death  of  the  fcrtus  may  lead  to  the  dis- 
appearance of  certain  signs  of  pregnancy  of  a  pathological  nature, 
and  their  disappearance  may  thus  come  to  have  a  diagnostic  \'alue. 
In  this  way,  for  instance,  varicose  veins,  dropsical  swelling  of  the 
lower  limbs  and  vulva,  and  alliuminuria  (A.  H.  F.  Barljour,  Ediiib. 
Med.  Journ.,  xxx.  901,  1SS4-5)  may  lessen  very  evidently,  even  if 
they  do  not  entirely  disappear.  The  same  remark  applies  to  several 
morbid  symptoms  of  pregnancy,  such  as  persistent  vomiting,  gra\  e 
dyspno?a,  etc. 

In  the  fifth  place,  fcetal  death  may  be  followed  by  certain  changes 
of  a  chemical  kind  in  the  maternal  excretions.  It  has  from  time  to 
time  been  somewhat  confidently  affirmed  that  in  the  presence  of  some 
unusual  substance  in  the  urine  is  the  certain  test  of  intrauterine 
death.  Thei-e  can  ha  little  doubt  that  with  tiie  decease  of  the  foetus 
a  current  begins  to  pass  from  the  uterus  and  its  contents  into  the 
general  maternal  circulation ;  this  current  will  contain  the  results  ol 
the  involution  of  the  uterine  muscular  fibres,  as  well  as  little  known 
substances  from  the  liquor  amnii,  fietus,  and  placenta.  Possilily  tlie 
immediate  result  of  post-mortem  changes  in  utero  is  a  marked  in- 
crease in  the  total  amount  of  urine  secreted ;  of  this  there  is  some 
evidence.  Witli  regard,  however,  to  the  value  of  acetonuria  as  a 
sign  of  f(Ptal  deatii  tlicre  has  lieen  much  diflerence  of  opinion.  The 
presence  of  acetone  in  the  urine  of  the  pregnant  w^unan  was  stated 
by  G.  VicarelU  {Prag.  mcd.  Wchnschr.,  xviii.'403,  428,  1893)  to  be  a 
new  sign  of  the  decease  of  the  fcetus  before  birth,  other  causes  being 


F(ETAL    DEATH  410 

excluded.  Eesearclies  were  made  by  others  (L.  M.  Bosai,  Ann.  di  ostct. 
C!)inc<:,  xvi.  276,  1894;  L.  Knapp,  CcntrlU.f.  Gyncih,  xxi.  417,  1897; 
H.  Lambinon,  Journ.  d'accouch.  (Liege),  xix.  70,  1898 ;  E.  Bidone. 
L'acdonuria  (jravidica,  Bologna,  1898;  Lop,  Gas.  d.  hop.,  Ixxii.  519, 
1899),  and  Vicarelli  himself  returned  to  the  subject  {liiv.  di  osfet.,  ii. 
o68,  1897).  The  fact  that  acetonuria  was  found  by  Bossi  {Arch,  di 
ostct.  c  gincc,  iv.  193,  1897)  in  cases  in  which  fibroid  tumours  of  the 
uterus  were  in  process  of  absorption,  formed  a  piece  of  continnative 
evidence,  and  seemed  to  suggest  that  the  acetone  was  due  to  the 
breaking  down  of  muscular  tissue.  A.  Couvelaire  {Ann.  dc  gyndc,  li. 
417,  1899)  is  of  opinion  that  acetouuria  in  the  puerperium  is  due  to 
the  neuro-muscular  fatigue  of  labour,  the  auto-intoxication  of  the 
fatigue  of  the  confinemeut  being  added  to  the  auto-intoxication  of 
pregnancy;  it  does  not  indicate  fcetal  death  with  any  certainty.  It 
cannot  yet  be  determined  what  value  acetonuria  has  as  a  sign  of  fcetal 
death ;  it  is  probably  not  developed  immediately  after  the  death  of 
the  infant,  and  it  may  of  course  lie  due  to  other  causes,  but  it  is  un- 
doubtedly of  some  importance ;  and  future  oliservations  will  more 
clearly  define  its  sphere  of  diagnostic  usefulness.  It  would  seem  to 
be  frecpiently  associated  with  eclampsia  and  syphilis. 

Another  possible  indication  of  intrauterine  death  is  peptonuria. 
A.  Kcettnitz  {Deutsche  mcd.  Wchnschr.,  xiv.  613,  1888)  met  with  this 
condition  in  four  cases  of  fcetal  death,  and  ascribed  to  it  considerable 
diagnostic  importance.  The  fact  that  peptoiruria  is  often  met  with 
in  the  puerperium,  and  after  the  application  of  electricity  to  fibroid 
tmnom-s,  supports  the  above  view,  indicating  that  the  peptone  comes 
from  the  involution  of  the  muscular  organisation  of  the  uterus.  After 
the  death  of  the  foetus,  the  uterus  is  practically  in  the  puerperium, 
although  its  contents  are  not  yet  expelled.  Further,  the  belief  is 
strengthened  by  the  observation,  made  liy  Truzzi  {Ann.  univ.  di  mcd., 
cclxxi.  409  ;  cclxxiii.  415, 1885),  that  peptonuria  is  absent  in  the  period 
following  the  expulsion  of  a  macerated  fcetus,  the  explanation  being 
that  here  the  puerperium  has  already  run  its  course  before  the  empty- 
ing of  the  uterus  takes  place.  The  experience  of  other  obstetricians 
has  not,  however,  come  to  support  the  opinion  of  Kcettnitz,  for  P. 
Caviglia  {Stud,  di  ostct.  c  gincc,  379,  1890)  and  some  others  have 
obtained  negative  results ;  again,  peptonuria  has  been  repeatedly 
foimd  in  cases  in  which  the  fcetus  was  alive.  It  has  sometimes  Ijeen 
supposed  that  one  might  find  traces  in  the  maternal  urine  of  other 
products  of  macerative  decomposition  of  the  tissues  of  the  dead 
fcetus,  such  as  htemoglobin,  bile  pigments,  glucose,  creatinin,  and 
urea ;  but  nothing  has  yet  been  discovered  of  real  diagnostic  value. 

It  is  perfectly  clear,  fi-om  what  has  been  said,  that  the  diagnosis 
of  foetal  death  must  always  be  a  matter  of  considerable  difficulty. 
When  a  multiparous  woman  passes  through  a  severe  illness  and 
affirms  that  she  feels  sure  that  her  unborn  infant  is  dead,  and  when 
her  medical  attendant  now  fails  to  hear  the  ffftal  heart  whicli  he 
had  previously  heard  with  ease,  the  probabilities  of  intrauterine 
death  rise  to  a  high  level ;  they  are  also  great  when  previous  ex- 
perience has  proved  the  existence  of  "  habitual "  foetal  death ;  but 


420  ANTENATAL    1' A  IlIOl.OdY    AND    IIYCIKNK 

under  other  circumstances  no  confident  diagnosis  should  l>e  made, 
and  the  obstetrician  should  be  prepared  for  surprises.  Wiieii  actual 
putrefaction  of  tlie  uterine  contents  takes  place,  the  condition  is 
different,  for  then  the  discharge  of  sanious  evil-smelling  tluid  and 
malodorous  gases  from  the  uterus,  along  with  tympanitic  distension 
of  that  organ  (physomelra)  and  grave  signs  of  maternal  lilood-jKuson- 
ing,  will  reveal  the  nature  of  the  processes  going  on  in  utero  (E. 
Chatelain,  Thtsc,  Paris,  1883).  Putrefaction,  however,  is  a  very  rare 
consequence  of  f(t'tal  death,  and  its  ])resence  nearly  always  means 
that  the  membranes  liave  ruptured,  and  that  air  has  gained  access  to 
the  uterine  interior  from  the  vagina. 

There  are  certain  conditions  wliich,  when  present,  greatly  increase 
the  difficulty  of  diagnosing  antenatal  dcatii.  These  are  the  existence 
of  twins  in  utero  or  of  an  extrauterine  gestation.  It  is  almost  im- 
possible to  give  anything  approaching  a  confident  answer  to  the 
question  whether  one  firtus  in  a  plural  pregnancy  lias  succumbed, 
and  the  hopes  of  determining  whether  the  extrauterine  infant  \v.\> 
died  are  scarcely  greater.  In  tliese  cases,  as  in  all  tiie  less  dillicult 
ones,  an  important  factor  in  clearing  up  tlie  diagnosis  is  time ;  the 
repeated  examination,  especially  by  mensuration,  of  the  abdomen  will 
in  the  long  run  throw  light  upon  the  problem,  and  by  and  by  the 
occurrence  of  labour  will  remove  all  doubt.  Insteiid  of  true  labour 
there  may  be  a  false  or  spurious  one,  resultless  as  regards  the  ex- 
pulsion of  any  uterine  contents,  but  with  a  certain  diagnostic  value 
nevertheless. 

Even  during  labour  some  dubiety  may  still  exist  as  to  tiie  life  ov 
death  of  the  fcetus  passing  through  the  birth  canals.  When  tiie 
head  presents  it  may  l:ie  possible  by  palpation  to  detect  tlu;  soft- 
ness of  the  presenting  part  and  tlie  crackling  sensation  of  the  easily 
displaced  cranial  bones ;  the  liquor  amnii  may  be  tinged  green  with 
meconium,  or  may  contain  flakes  of  desquamated  epidermis ;  and  any 
prolapsed  part  (liand,  foot,  etc.)  may  show  signs  of  maceration. 
When  these  conditions  are  present,  the  diagnosis  of  fo>tal  death 
may  be  made ;  but  it  is  noteworthy  that  the  presence  of  meconiiuu 
in  the  amniotic  fluid  is  not  a  certain  sign  (E.  Eossa,  Arch./.  Gynad:, 
xlvi.  303, 1894).  Further,  a  swelling  may  be  found  on  the  presenting 
part  of  a  dead  fcetus,  not  distinguishable  by  touch  from  the  caput 
succedaneum  which  is  formed  in  ordinary  labour.  Death  during 
labom-  will  be  diagnosed  l)y  the  occurrence  of  some  evident  cause, 
by  cessation  of  the  fo'tal  lieart  and  of  pulsation  in  the  cord  or  other 
palpable  part,  and  by  tlie  ]iremature  escape  of  meconium.  1 1'  doubt 
exist,  it  will  soon  be  set  at  rest  by  the  complete  expulsion  of  the 
infant,  alive  or  dead. 

Pathology  of  Fcetal   Death. 

I  have  already  indicated  the  changes  which,  in  all  probability, 
immediately  follow  upon  the  cessation  of  the  life  of  the  fetus  (sub- 
pleural  ecchymoses,  rigor  mortis,  etc.) ;  liut  it  is  now  necessary  to 
consider  the  less  immediate  post-mortem  alterations  which  occur  in 


PATHOLOGY   OF   F(ETAL   DEATH  421 

the  dead  unbin'ii  infant  and  in  its  environment.  The  subject  is  com- 
phcated  by  tlie  difticnlty  of  separating  the  true  post-mortem  changes 
from  those  due  to  ante-mortem  disease,  and  by  the  lack  of  reliable 
descriptions  of  the  changes  at  various  definitely  ascertained  dates 
after  death. 

Four  varieties  of  pathological  change  are  usually  enumerated  in 
connection  with  antenatal  death,  viz.,  dissolution,  mummification, 
maceration,  and  putrefaction.  With  regard  to  dissolution  or  the 
gradual  disappearance  of  all  traces  of  tlie  embryo  in  the  liquor 
amnii,  it  may  be  fairly  confidently  affirmed  that  it  can  occur  only 
in  the  embryonic  period  of  antenatal  life  as  a  result  of  early  death 
of  the  new  organism ;  it  is  not,  therefore,  to  l)e  reckoned  as  one  of 
the  post-mortem  changes  incident  upon  ftctal  death.  Mummification 
is  a  peculiar  drying  up  of  the  fu'tal  tissues  which  occurs  only  under 
special  circumstances ;  to  it  reference  will  be  made  ere  long.  Putre- 
faction probably  occurs  only  after  the  rupture  of  the  membranes  has 
taken  place  and  air  has  gained  access  to  the  uterus.  Maceration, 
therefore,  remains  as  the  commonest  and  most  typical  of  the  post- 
mortem changes  which  follow  fcetal  death. 

All  the  stages  of  maceration,  a,^  it  affects  the  frotus  and  its 
annexa,  are  unfortunately  not  known.  The  immediate  consequences 
of  intrauterine  death  and  those  which  are  found  about  a  fortnight 
later  have  been  fairly  well  ascertained ;  but  of  the  changes  which 
develop  between  these  times  our  knowledge  is  very  imperfect.  For 
it  is  common  for  the  foetus  to  lie  expelled  very  soon  after  its  death 
or  not  till  ten  or  fourteen  days  have  elapsed,  but  rare  for  it  to  be 
born  at  intermediate  dates.  If  the  death  of  the  fcetus  is  not  accom- 
panied by  its  expulsion,  it  is  common  for  a  sort  of  spurious  laboiir  to 
occur ;  this  is  apparently  without  result,  and  the  dead  fa?tus  is  re- 
tained for  a  fortnight  or  so.  During  these  fourteen  days,  various 
changes  have  been  occurring  in  the  uterus  which  usually  are  met 
with  in  the  first  fortnight  of  the  puerperium.  Save,  indeed,  for  the 
fact  that  it  is  not  empty,  the  uterus  is  practically  a  puerperal  organ, 
and  by  the  end  of  fourteen  days  or  thereabout  the  dead  foetus  inside 
it  is  a  foreign  body.  This  is  probalily  one  reason  for  the  commonly 
observed  fortnight's  retention.  At  the  same  time,  much  longer 
periods  of  retention  have  been  recorded.  I  have  myself  observed 
a  case  (215)  of  missed  abortion,  in  which  the  fretus  died  at  the  third 
month  and  was  retained  tQl  the  ninth,  being  ultimately  expelled 
upon  what  would  probalily  have  been  the  date  of  confinement  had 
the  foetus  lived ;  and  many  such  observations  have  been  made.  It 
would  seem  to  be  much  rarer  for  the  dead  fwtus  to  be  retained  for 
some  weeks  or  months  after  the  full  term  of  gestation  ;  and  most  of 
the  cases  in  which  it  was  stated  that  the  infant  was  discharged  or 
discovered  after  a  sojourn  of  seven,  ten,  twenty,  and  even  forty  years 
in  the  mother's  body,  are  to  be  regarded  as  instances  of  extrauterine 
or  interstitial  pregnancy.  B.  F.  Baer,  however,  reports  an  extra- 
ordinary case  (Amcr.  Journ.  Obst.,  xv.  229,  1882),  in  which  there  was 
a  punctured  wound  of  the  uterus,  partial  escape  of  the  foetus  into  the 
abdominal  cavity,  and  retention  of  it  for  five  years.     From  what  has 


422  ANIKNATAI.    PA TllOl.OdY    AND    IlYCIl-.NK 

been  said,  it  will  Ije  (n'iileiiL  that  most  of  our  knowledge  regavdiiig 
maceration  applies  to  the  maceration  found  about  a  fortnight  after 
intrauterine  death. 

The  external  appearances  and  the  internal  alterations  of  the 
macerated  fretus  vary  with  tlie  period  which  has  elapsed  since  death. 
They  have  been  specially  studied  by  A.  Lenipereur  {T/ihc,  Paris, 
1867),  by  L.  Sente.x  {Mrm.  ct  hull.  Soc.  med.-chir.  d.  luq^.  dc  Jiordcaux, 
ii.  486-572,  18G7),  by  O.  Hourlier  {Thtsc,  Paris,  1880),  and  by  others. 
The  process  consists  in  a  gradual  softening  of  tiie  tissues  of  the  body 
without  the  development  of  putrefactive  gases  or  the  presence  of 
microbes ;  it  is  an  aseptic  change.  It  used  to  be  termed  "  putre- 
faction "  by  the  older  authors,  but  that  name  ought  to  be  restricted 
to  the  cases  in  wliicli  putrefactive  germs  have  gained  access  to  tlic 
interior  of  the  uterus  and  s(!t  up  true  putrefaction. 

In  the  Jirst  stage  of  maceration,  which  corresponds  with  the  fir.«t 
ten  or  twelve  days  following  intrauterine  deatii,  the  e.xternal  form 
of  the  foetus  is  hardly  modified,  and  the  parts  retain  their  lirmness. 
The  epidermis  here  and  there  (limbs,  neck,  etc.)  is  raised  u]>  into 
Itlebs  containing  blood-stained  serum ;  some  of  these  may  have  burst 
and  their  contents  passed  into  the  liquor  amnii  to  mix  witii  it  and  with 
tiie  meconium  in  it.  In  the  body  cavities  there  is  found  a  more  or 
less  clear  serum, and  the  organs  are  somewhat  soft;  the  subcutaneous 
tissue  is  infiltrated  with  serum,  and  the  braiii  siiows  some  softening, 
especially  in  the  grey  matter.  In  the  second  stage,  tenth  day  to 
fortieth  (Lempereur),  the  macerative  changes  have  become  very 
marked.  They  are  represented  as  they  appear  in  a  frozen  section 
in  Plate  XIV.  This  foetus,  a  male,  came  into  my  hands  for  ex- 
amination in  1893,  and  1  made  sections  of  it  after  freezing  in  order 
to  bring  out  certain  peculiarities  not  easily  recognised  by  other 
methods.  It  had  been  dead  for  fully  a  fortnight.  At  this  stage 
the  whole  fo'tus  is  somewhat  swollen,  but  on  account  of  its  softness 
tends  to  flatten  out  on  any  liard  surface  upon  which  it  may  be  laid. 
The  abdomen,  in  particular,  flattens  out,  as  does  the  head  in  au 
antero-posterior  direction.  The  epidermis  is  absent  over  nearly  the 
whole  surface  of  the  body,  leaving  the  dull  red  underlying  skin  fully 
exposed.  On  the  scalp,  however,  it  is  still  attached.  Tlie  cranial 
bones  move  freely  oil  each  other,  and  the  scalp  tissues  are  swollen 
and  infiltrated  with  sero-sanguinolent  fluid,  w4iich  may  accumulate, 
especially  at  the  vertex,  and  produce  a  spurious  caput  (Plate  XIV.). 
Everywhere  there  is  found  this  sero-sanguinolent  fluid — in  the  sub- 
cutaneous tissue,  between  the  muscles,  in  the  abdomen,  in  the 
thorax  ;  so  constant  and  so  copious  is  it,  that  C.  Euge  gave  the 
name  hydroi^s  sanginnolcntus  to  the  fcetus  in  this  stage  of  maceration 
{ZtscJir.  f.  Gehurtsh.  u.  Gymik.,  i.  57,  1877),  and  the  name  was  quite 
warrinited,  although  it  came  erroneously  io  be  regarded  as  equivalent 
to  the  syphilitic  dead  fietus.  All  the  internal  organs  show  softening, 
and  the  brain  is  quite  difliuent,  only  maintaining  its  form  by  the 
help  of  the  surrounding  membranes.  The  heart,  the  liver,  the  spleen, 
and  the  lungs  are  all  more  or  less  altered  in  shape  on  account  of 
their  softness ;  they  may  be  pale  in  colour,  or  stained  to  a  greater  or 


Blood- st  a  irud 
subcutaneous 
and  tnuscufar 

tissue. 


i_.    „su,. 
Cap'ng  mouth. 
{^^^/n/.nor  maxilla 
th  tooth  in  socket. 


PATHOLOCY   OF   FCETAL    DEATH  423 

less  degree  with  blood.  Under  the  microscope,  the  epithelial  ele- 
ments of  the  tissues  can  be  recognised  as  swollen  and  granular  or 
fatty  in  appearance;  the  changes  in  the  stroma  of  the  organs  are 
little  known :  and  the  blood  corpuscles  may  be  found  swollen  and 
paler  in  colour  than  normal,  or  else  shrivelled  and  broken  up  into 
granular  masses.  The  colouring  matter  of  the  blood  is  dissolved  in 
the  fluids  of  the  body  cavities,  or  lies  as  small  crystals  in  the  tissues. 
During  the  second  stage  of  maceration  the  histological  elements  of 
most  of  the  organs  and  tissues  become  unrecognisable.  In  the  third 
stage,  which  last.s,  according  to  Lempereur  (o^j.  cit.),  from  the  fortieth 
to  the  sixtieth  day  of  intrauterine  retention,  the  cellular  elements 
of  even  the  lungs  are  unrecognisable.  The  absence  of  the  epidermis 
is  now  complete,  and  is  seen  even  on  the  hairy  scalp ;  the  softening 
of  the  liody  is  very  marked ;  the  internal  organs  rest  in  a  collapsed 
state  upon  the  vertebral  column ;  and  the  lirain  is  simply  an  "  emul- 
sion of  nerve  tissues." 

The  post-mortem  changes  which  ensue  when  the  foetus  is  retained 
in  the  uterus  longer  than  two  months,  are  not  well  known.  Some- 
times the  maceration  proceeds,  and  the  body  breaks  up  and  is  expelled 
in  fragments  at  various  times ;  sometimes  true  putrefaction  is  set  up, 
necessitating  the  artificial  clearing  out  of  the  uterus  ;  sometimes  pos- 
sibly all  that  remains  in  the  uterine  cavity  may  lie  the  dry  skeleton 
of  the  fcetus:  and  possibly  also  petrification  or  saponifiaition  may 
occur.  It  is  difficult,  however,  to  determine  whether  the  results 
above  named  occur  save  in  cases  of  extrauterine  gestation  in  which 
the  fcetus  has  died. 

There  is  also  a  great  lack  of  knowledge  respecting  the  changes 
which  occur  in  the  fcetal  annexa  after  the  death  of  the  unborn  infant. 
The  placenta  may  show  various  alterations,  e.g.,  fibrous  degeneration, 
fatty  changes ;  but  it  is  always  very  difficult  to  exclude  the  pos.si- 
bility  of  ante-mortem  disease  of  the  organ.  Even  in  twin  cases  in 
which  one  foetus  is  dead,  and  in  which  the  part  of  the  placenta  from 
wliich  it  derived  no\irishment  is  affected  with  fibrous  or  fatty  change, 
it  is  still  an  open  question  whether  the  changes  are  the  results  or  the 
causes  of  the  fotal  death.  I  have  several  times  been  impressed  by 
the  fact  (as  indeed  I  suppose  all  obstetricians  have  been)  that  the 
placenta  may  have  an  almost  normal  appearance,  and  yet  be  expelled 
along  with  a  fcetus  which  has  evidently  been  dead  for  some  time ;  on 
the  other  hand,  I  have  noted  tlie  conversion  of  a  large  part  of  the 
placenta  into  fibrous  tissue  with  functional  destruction  of  a  great 
number  of  villi,  and  yet  the  infant  has  been  born  alive  and  well 
nourished.  Evidently  the  placenta  has  a  certain  degree  of  vital 
independence  as  regards  the  fretus ;  evidently  also  the  pilacenta 
always  contains  many  more  villi  than  are  absolutely  necessary  for 
the  conservation  of  fcetal  life  and  health.  Nature  plans  with  no 
niggard  hand.  When  the  fcetus  has  been  born  dead  and  markedly 
macerated,  I  have  found  villi  in  the  placenta  containing  apparently 
normal  blood-cells,  and  I  do  not  regard  it  as  an  impossibiUty  that  the 
placenta  may  increase  somewhat  in  size  after  the  decease  of  the 
unborn  infant.     As  a  rule,  however,  the  cessation  of  the  circulation 


424  ANTHNATAF.    I' A  TllOLOdY    AND    HYCHKNE 

tliroui;li  the  placouUi  is  ]]i(il)iiljly  fnlloWL'd  l)y  the  riinnalinn  of 
thrombi  in  the  vessels  of  tlie  villi,  and  by  the  development  of  filn-in 
in  their  neighbourhood,  and  there  may  be  signs  of  iiiHanimatory 
processes  i-ound  them.  Winkler  {Dissert.,  Wurzburg,  1895),  at  any 
rate,  describes  perivascular  inflammation  and  obliteration  of  vessels 
of  the  villi  as  signs  of  fietal  death  ;  but  Otto  von  Fraiique  {Ztsc/ir.f. 
Gcburtsh.  u.  Gyndlc,  xxxvii.  277,  1897)  is  very  guarded  in  drawing 
conclusions.  Changes  of  various  kinds  have  been  met  with  in  the 
umbilical  cord  (gelatinous  infiltration,  vascular  inilammation),  in  the 
chorion  and  amnion  (loss  of  transparency,  thickening,  so  -  called 
choriitis  and  amuionitis),  in  the  liquor  amuii  (al)sorption,  increase 
in  quantity),  and  in  the  decidual  membranes;  but  what  has  been 
already  said  regarding  the  placental  alterations  in  structure  may 
be  liere  repeated — it  is  very  doubtful  whether  they  precede  or 
follow  the  fcetal  death.  It  is  quite  possible  that  there  may  be  a 
much  greater  degree  of  independence  between  the  vitality  of  the 
fcetus  and  that  of  its  annexa  than  has  been  hitherto  supposed,  and 
that  when  the  cause  of  fcetal  death  resides  in  the  fiL'tus  itself  the 
life  of  the  placenta  may  to  a  certain  extent  be  continued.  When,  on 
the  other  hand,  the  fo'tus  dies  because  the  placenta  is  practically 
dead,  the  dependence  will  be  more  manifest.  We  think  of  the  semi- 
parasitism  of  the  ftPtus  as  regards  the  motlier ;  we  may  liave  to  think 
of  the  semi-parasitism  of  tlie  placenta  both  as  regards  tlie  mother  and 
the  foetus. 

As  has  been  already  stated,  mummification  is  a  peculiar  result  of 
fcfital  death,  perhaps  similar  to  the  preserving  of  a  fruit  in  a  liqueur 
or  the  pickling  of  meat  in  brine.  It  would  seem  to  occur  specially 
in  early  fcetal  and  in  neofrctal  death  (third  or  fourth  montli) :  and 
it  is  characterised  by  a  drying  up  or  tanning  of  the  fietal  tissues,  by 
the  alisence  of  the  liquor  amnii,  or  by  the  presence  of  some  drops  of 
muddy  Hnid  representing  it,  and  by  the  close  contact  which  exists 
between  the  fu:'tus  and  its  enveloping  membi-anes.  This  desiccative 
process  produces  its  most  striking  result  when  one  of  twin  fcetuses 
dies  in  utero  and  is  pressed  upon  by  the  other,  wliich  continues  to 
live  and  grow.  Then  the  so-called  fcetiiA  comprcssus  scti  jiajii/raceus  is 
produced  ;  in  it  there  is  tiattening  as  well  as  desiccation,  and  tlie 
result  is  not  imlike  the  gingerbread  figures  sold  at  fairs  ("  des 
Ijonshommes  de  pain  d'cpice  ").  I  have  met  with  several  specimens 
of  the  foetus  compressus  (159,  180,  190),  and  in  all  of  them  the 
flattened  twin  liad  its  own  placenta ;  in  all  of  them  fa^tal  death  had 
occurred  about  the  second  or  third  month,  but  the  dead  fictus  had 
not  been  expelled  till  the  full  term  along  with  the  living  infant. 
There  may,  how^ever,  be  a  common  placenta,  as  in  H.  J.  Ilott's 
specimen  (Trans.  Ohst.  Soc.  Lond.,  xxxvii.  16,  1895). 

When  tlie  dead  ficlus  lies  in  an  dtrautcrine  f/csfatio7i  sac,  it 
may  undergo  tlie  post-mortem  changes  of  maceration  and  desiccation 
which  have  been  described  above ;  it  may  also  putrefy.  The  other 
changes  wliich  are  of  doubtful  occurrence  in  intrauterine  death  niostr 
certainly  occur  in  the  ectopic  pregnancy.  TIius  tlie  ftctus  may  br 
converted  into  adipocere  (sa])oiiitication)  or  into  a  lithopa'dion  (calci- 


ABORTION  425 

fication,  petrifaction).  Sometimes  the  deposit  of  lime  salts  affects 
only  the  fa'tal  membranes,  sometimes  it  would  seem  as  if  the  vernix 
easeosa  had  been  changed  into  a  calcareous  shell,  and  sometimes  the 
lime  is  distributed  throughout  the  foHus  itself  (true  lithop;udion). 
The  mode  of  formation  of  the  adipocere  and  lithopffidion  are  not 
understood.  A  good  account  of  tlie  microscopical  appearances  of  the 
lithop;edion  was  given  by  Inez-Gaches  Sarraute  (Arch,  de  tocoL,  xii. 
237,  1S85) ;  and  J.  G.  Clark  {£u!l.  Johns  Hopkins  ffosj}.,  viii.  221, 
1897)  has  furnished  a  long  bibliographical  list,  bringing  F.  Kiichen- 
meister's  record  {Arch.  f.  Gri/naeL,  xvii.  153,  1881)  up  to  date.  J.  C. 
Webster  {Ectopic  Pregnancy,  p.  102,  1895)  lias  referred  to  the  occur- 
rence of  h;emorrhages  m  the  placenta  after  the  death  of  the  foetus  in 
ectopic  gestation. 

Upon  the  whole  subject  of  the  morbid  anatomy  of  foetal  death, 
W.  0.  Priestley's  Lunileian  lectures  {Pathology  of  Intrauterine  Death, 
London,  1887)  may  be  consulted  with  great  profit. 

AVhile  tlip  changes  which  have  been  described  above  are  going  on 
in  the  fcetus  and  its  annexa,  the  uterus  is  passing  through  a  sort  of 
puerperium.  So  far  as  is  possible  in  its  iniemptied  state,  the  womb 
undergoes  involution.  Tlie  muscular  and  vascular  hypertrophy  in 
its  walls  disappears,  and,  if  we  may  draw  conclusions  from  Orloff's 
case  {Frag.  mcd.  IVchnschr.,  xx.  232,  1895),  the  mucous  membrane  is 
restored  when  the  retention  is  long  continued.  But,  as  every 
obstetrician  knows,  the  usual  result  of  ftetal  death  is  abortion  or 
premature  laliour,  and  not  prolonged  retention  of  the  products  of 
conception.  Let  us,  therefore,  consider  abortion  from  this  stand- 
point. 

Abortion  and  Premature  Labour. 

It  is  not  my  intention  to  describe  in  any  fulness  the  causes, 
mechanism,  diagnosis,  and  treatment  of  abortion  and  premature 
labour ;  these  matters  are  dealt  with  in  all  text-books  of  luidwifeiy. 
I  sliall  here  consider  only  aboition  and  premature  labour  in  so  far  as 
they  concern  foetal  death. 

In  the  first  place,  abortion  does  not  always  follow  fwtal  death 
immediately,  neither  does  prematiu-e  labour.  As  has  been  pointed 
out  above,  the  dead  fcetus  may  be,  and  often  is,  retained  for  a  varying 
period  in  utero.  This  is  proved  by  the  more  or  less  advanced  signs 
of  post-mortem  change  so  often  found  in  it  when  it  is  expelled.  Can 
this  be  explained  ?  I  think  it  may  possibly  be  due  to  several  causes. 
First,  there  is  reason  to  believe  that  there  are  special  dates  in  preg- 
nancy at  which  it  is  more  likely  that  the  uterus  will  empty  itself 
than  at  others.  That  these  dates  correspond  to  what  would  have 
been  menstrual  periods  if  pregnancy  had  not  occurred,  is  very  prob- 
able, as  indeed  L.  M.  Bossi  {Ann.  cli  ostet.  e  ginec,  xxi.  445,  1899) 
has  pomted  out.  '  It  is  cjmte  rational  to  think  that  if  foetal  death 
occur  just  before  one  of  these  dates,  with  perhaps  its  recurrent  pehic 
congestion,  the  expulsion  of  the  uterine  contents  will  follow  immedi- 
ately; whereas  if  it  take  place  midway  between   two  periods,  the 


426  AXTF.NATAI.    I'A  11 1()I,()(!V    AND    1 1^(  11  K.NF, 

uterus  may  not  eniply  till  tin-  next  date.  It  may  lie  that  at  these 
times  there  is  an  (rstious  toxin  which,  circulating  in  the  blood, 
increases  uterine  excitability.  Second,  there  is  the  transition  time 
of  neoftt'tal  life,  which  is  a  period  wlien  there  is  a  special  lialiility  to 
the  occurrence  of  abortion.  At  this  time  a  delicate  readjustment  of 
intrauterine  atlairs  is  taking  place,  for  tlie  general  choriimic-decidual 
attaclunents  are  loosening,  and  the  placental  ones  are  not  yet  fully 
formed  and  secure ;  fa-tal  death  or  any  otiier  disturbing  cause  arising 
now  will  be  much  more  likely  to  cause  the  emptying  of  the  uterus 
than  at  other  times. 

In  tlie  second  place,  neither  abortion  nor  ])remature  laliour  by 
any  means  always  implies  preceding  fcctal  death.  Fo'tal  death  is 
only  one  of  many  possible  causes  of  abortion  and  premature  labour. 
It  is  true  that  most  of  the  cau.ses  of  intrauterine  death  may  be  also 
causes  of  a])ortion  ;  but  it  is  not  very  rare  to  find  a  living  fo/tus  in 
an  abortion  sac,  and  prematurely  born  babies  are  of  course  frequently 
born  alive.  A  certain  cause  may  produce  abortion  without  killing 
the  foetus,  just  as  another  cause  may  kill  the  f(Ptus  without  leading 
to  its  expulsion.  What,  then,  are  the  causes  wiiich  lioth  kill  the 
fcetus  and  produce  abortion  or  premature  laliour  ?  Theoretically,  we 
maj'  suppose  that  they  are  those  which  attack  in  a  special  way  the 
placenta ;  and,  practically,  there  is  some  reascm  to  believe  that  this 
conclusion  is  justified.  Certainly  syphilis,  which  produces  marked 
placental  changes,  is  a  very  frequent  cause  of  both  fcetal  death  and 
abortion  or  premature  lal)our.  As  a  matter  of  fact,  it  would  seem 
that  the  life  of  the  placenta  (or  at  least  its  functional  integrity)  is 
more  necessary  for  the  maintenance  of  the  intrauterine  statim  quo 
than  that  of  the  fcetus  itself.  I'l-obabl)'  this  i.s  one  reason  why  in  a 
given  case  the  slightest  cause  will  lead  to  the  emjitying  of  the  uterus, 
while  in  another  case  serious  injury  and  the  most  provocative 
abortifacients  will  not  suffice.  In  the  one  the  placenta  i.s  prone 
to  disease  or  is  already  morbid,  in  the  other  it  is  not.  No  doubt 
there  is  also  that  curious  and  variable  factor,  utei'ine  irritability,  to 
which  I  have  referred  in  a  recent  lecture  on  "  Abortions  "  (12Gi). 
The  abortinfi  coefficient  is  to  be  arrived  at  by  the  consideration  of  the 
cause  in  action  plus  the  uterine  irritability.  If  tiie  total  stimidus  be 
represented  by  100,  then  in  some  cases  the  exciting  cause  may  be  45 
and  the  uterine  irritability  will  require  to  be  55  in  order  to  lead 
to  abortion ;  in  other  cases  the  uterine  irritability  will  be  95,  then 
an  exciting  cause  represented  by  5  will  be  sufficient  to  produce 
the  .same  effect.  Of  course,  neither  factor  can  be  fixed  exactly,  but 
when  we  are  deaUng  with  patients  we  soon  begin  to  know  those  with 
a  high  degree  of  uterine  irritability,  and  to  take  altogether  dill'erent 
means  to  prevent  miscarriage  with  them.  Sjiecially  nuist  the 
aborting  coeilicicnt  be  borne  in  mind  in  cases  of  recurrent  abortion. 

Wlien  we  study  the  mechanism  of  abortion  more  fully,  it  becomes 
clear  that,  in  the  early  fcetal  period  at  any  rate,  the  expulsion  of  the 
uterine  contents  is  dependent  more  upon  the  state  of  the  decidual 
membranes  than  u]ion  tiie  life  or  death  of  the  foitus.  As  has  lieen 
demonstrated  by   D.   P>erry   Ilart  (Trans.  Edinh.  Ohst.  Soc.,  xvi.  20, 


CAUSES   OF   F(ETAL   DEATH  427 

1891),  in  "  normal  and  complete"  abortion,  the  decidua  is  first  separ- 
ated over  the  lower  uterine  segment  and  later  over  the  wliole 
interior  above  the  lower  segment,  with  consequent  expidsion  of  the 
whole  mass ;  or  else  the  part  of  tlie  ovum  covered  by  retlexa  is  driven 
down  into  the  cervical  canal  before  the  complete  separation  of  the 
part  covered  by  the  vera.  In  "  abnormal"  forms,  the  separation  may 
occur  in  other  planes;  the  foetus  and  liquor  amuii  alone  may  he 
expelled,  or  the  whole  chorionic  sac  and  its  contents  may  be  driven 
down  imcovered  by  the  deciduic,  or  the  foetal  sac  in  the  decidua 
reflexa  may  be  separated  fii-st  from  the  vera  and  later  from  the 
serotiiia.  Various  parts  of  the  products  of  conception  may  thus  be 
retaiued,  constituting  incomplete  abortion.  Possibly  the  life  or  death 
of  the  ftetus  may  explain  some  of  these  varieties  of  abortion,  but 
manifestly  the  state  of  attachment  of  the  decidual  and  fa?tal  mem- 
branes will  be  a  very  important,  perhaps  a  dominating  factor. 

In  the  case  of  premature  labour,  it  will  be  admitted  that  tlie  death 
of  the  fcetus  has  a  more  immediate  bearing  upon  the  supervention  of 
labour  than  in  abortion.  Yet,  even  here,  as  clinical  records  show, 
the  dead  fcetus  may  be  retaiued  for  some  days  in  utero.  This  delay 
is  by  no  means  unfavourable  for  the  mother,  whom  perhaps  it  saves 
from  infection  by  allowing  the  involutiouary  processes  in  the  uterine 
walls  to  be  to  some  extent  completed  before  the  separation  of  the 
placenta  and  membranes  takes  place.  If  the  cause  which  has  led  to 
the  foetal  death  do  not  at  once  produce  also  premature  labour,  then 
the  uterine  contents  remain  in  situ  till  the  occurrence  of  changes  in 
the  uterine  walls  converts  the  foetus  and  its  anuexa  into  a  "  foreign 
body,"  .so  far  as  the  containing  organ  is  concerned. 

Causes  of  Foetal  Death. 

From  what  has  been  said,  the  reader  will  now  be  prepared  to 
recognise  that  the  long  lists  of  causes  of  fa-tal  death  given  in  the 
text-books  are  in  some  senses  unnecessary.  They  are  not  repeated 
here,  for,  as  I  have  tried  to  point  out  as  each  chapter  of  the  work  was 
written,  all  the  various  pathological  states  of  the  fcetus  and  its  aunexa 
may  lie  causes  of  death,  just  as  the  various  morbid  states  of  postnatal 
existence  may  also  produce  a  fatal  issue.  They  do  not  always  or  with 
certainty  do  so,  for  there  are  several  factors  to  be  taken  into  account, 
such  as  severity  and  extent  of  the  pathological  process,  power  of 
I'esistance  of  the  organism,  degree  of  placental  permeability,  etc. 
One  certain  cause  of  foetal  death  is  the  premature  expulsion  of  the 
fretus  from  the  uterus  before  the  sixth  month ;  strictly  speaking, 
this  is  not  intrauterine  death,  but  fcetal  death,  due  to  a  too  early 
entrance  into  extrauterine  existence.  Possibly  as  the  means  for 
rearing  premature  infants  are  perfected,  even  this  certain  cause  of 
fu'tal  death  may  become  less  sure,  and  the  date  of  viabihtybe  puslied 
further  back  than  it  is  at  present. 


428  ANTKNATAI.    I'A  TilOI.OCY    AND    HYCilENE 

Treatment. 

Foetal  doalh  is  conft'sscilly  a  failure  and  a  (li.sa])])()iiitiiicnt,  and 
the  treatment  it  calls  for  is  provciilion.  To  prevent  fo'tal  death 
means,  of  course,  to  abrogate  the  causes  thereof,  and  in  process  of 
time  we  sJiall  doubtless  be  better  able  to  do  so  than  at  i)resent.  The 
eUmination  of  certain  notorious  causal  conditions,  such  as  syphilis 
alcoholism,  and  lead-poisoninc;,  would  reduce  in  a  sLartling  fashion 
the  mortality  of  intrauterine  life  ;  but  much  must  lie  accduiplished 
before  any  one  of  these  well-known  causes  can  be  got  rid  of  or 
rendered  innocuous.  Failing  the  j)ower  of  eliminating  Ihe  causes  of 
fo_^tal  death,  it  has  been  proposed,  in  cases  in  which  the  hetus 
"  habitually "  perishes  in  the  last  month  of  intrauteiine  life,  to 
induce  premature  labour  so  as  to  send  the  hetus  forth  alive.  If  the 
cause  of  death  reside  in  the  placenta,  this  plan  may  pcnchance 
succeed ;  if  in  the  fo'tus  itself,  the  result  will  be  most  problematical. 
In  cases  in  which  the  fu'tus  dies  in  labour  on  account  of  too 
advanced  ossification  of  the  head,  the  idea  of  the  induction  of  labour 
is  well  founded  and  may  prove  successful ;  but  of  couise  it  is  always 
difficult  to  exclude  the  fallacy  arising  from  simple  coincidence ;  for 
the  pregnancy  in  which  induction  was  performed  might  have 
terminated  in  the  birth  of  a  living  infant. 

If  there  be  reason  to  suppose  that  the  foetus  is  dead  in  utero,  the 
question  of  obstetric  interference  will  arise.  If  the  membranes  are 
intact,  the  expectant  plan  is  to  be  followed,  for  during  the  next  week- 
changes  will  occur  in  the  ])lacenta,  membranes,  and  uterine  wall 
which  will  greatly  diminish  the  risks  of  sepsis  and  luemorrhage  in 
labour.  When  uterine  contractions  supervene,  the  exj)ulsion  of  the 
foetus  and  annexa  will  not,  in  most  case.s,  be  delayed,  and  the 
recovery  may  be  expected  to  be  rapid.  If,  however,  the  membranes 
rupture,  and  yet  no  signs  of  labour  occur,  the  question  of  inter- 
vention is  more  difficult  to  decide.  There  is  now  the  risk  of  putre- 
faction in  utero  with  all  its  attendant  dangers.  On  the  whole, 
perhaps,  it  will  be  best,  in  the  absence  of  signs  of  maternal  infection, 
to  await  the  onset  of  uterine  contractions;  but  iu  the  jiresence  t>f 
such  signs  and  symptoms  it  will  become  imperative  to  empty  the 
uterus  expeditiously,  and  to  use  all  the  means  in  our  power  to 
diminish  the  septic  absorption.  A  very  important  factor  in  giuding 
our  conduct  in  all  such  cases  is  the  difficulty  of  determining  with 
anything  like  certainty  the  actual  occurrence  of  foetal  death.  When 
everything  seems  to  point  to  the  foHus  being  dead,  the  obstetrician 
may  be  surprised  to  find  a  living  infant  expelled.  In  the  jiresence 
of  this  uncertainty,  the  intervention  of  the  medical  attendant  may 
serve  no  good  purpose,  and  may,  indeed,  produce  evil  eh'ccts  and 
precipitate  dangers.  The  use  of  antejiartum  antiseptic  douches  may 
be  permitted,  but  they  must  be  administered  with  caution.  What 
has  been  said  as  to  expectancy  in  treatment  applies  to  f<etal  death 
lioth  iu  the  early  and  in  the  later  months  of  pregnancy.  It  must, 
further,  be  borne  in  mind  that  when  the  olistetriciaii  has  to  empty  a 
uterus  h(>  will  find  that  his  most  valuable  allv  is  the  uterus  itself; 


TREATMENT   OF   F(KTAL   DEATH  429 

in  other  words,  uterine  contractions  make  the  operation  very  easy, 
their  absence  malces  it  one  of  the  most  difficult  of  tasks. 

There  is  much  yet  to  be  learned  regarding  foital  deatli,  regarding 
its  mechanism,  its  symptoms  and  signs,  its  diagnosis,  its  pathology, 
its  causes,  and  most  of  all  regarding  its  preventive  treatment.  But 
every  advance  in  our  knowledge  of  the  various  departments  of 
Antenatal  Pathology  will  in  the  long  run  tend  to  diminish  the 
frequency  of  intrauterine  death.  In  the  meantime,  it  must  be  said 
sadly  that  the  fcetus  has  indeed  the  gift  of  antenatal  life  accom- 
panied by  the  risk  of  antenatal  death. 

"  L'teuf  fcconde  jouit  de  la  vie,  sujet  par  consequent  aux  maladies, 
a  la  mort."  "  Ad  mortem  maturi  omnes  sumus,  etiam  antequam 
nati."  To  these,  from  other  lands,  I  may  add  the  words  of  Sir  Thomas 
Browne  {Letter  to  a  Friend) :  "  Nothing  is  more  common  with  infants 
than  to  die  on  the  day  of  their  nativity,  to  behold  the  worldly  hours 
and  but  the  fractions  thereof ;  and  even  to  perish  before  their 
nativity  in  the  hidden  world  of  the  womb,  and  before  their  good 
angel  is  conceived  to  vuidertake  them." 


CllAI'TKi;    XXV 

Diagnosis  of  Futal  Morbirl  States  :  Ditlicullics  and  Scope  ;  Antenatal  Diaj^osis, 
Maternal,  Medical,  and  Reiuoductive  History,  Paternal  and  Family 
History,  Maternal  Syniptuniatoldi^y  and  Pliysical  Exandnation,  Physical 
Exaininaliuu  of  tlic  Fnlus  ;   intranalal  and  Postnatal  Diagnosis. 

ITeke  and  there  tlirrmghout  thi.s  work,  allusions  liave  been  made  to 
the  diagnosis  of  antenatal  morbid  states  atl'ecting  tlie  fcrtus ;  thus 
under  variola  (p.  19:!),  malaria  (p.  202),  sypiiilis  (jx  237),  general 
dropsy  (p.  296),  endocarditis  (p.  372),  hydramnios  (p.  402),  and  i'(Ptal 
death  (p.  416),  some  space  has  been  given  to  the  subject.  Now, 
however,  it  is  necessary  to  draw  together  into  one  chajiter  these 
scattered  allusions,  and  to  attemjtt  to  juvsent  in  a  more  systematic 
fashion  the  means  at  our  disposal  for  the  makhig  of  an  antenatal 
diagnosis. 

Diagnosis  implies  diftictdty.  The  making  of  a  successful 
diagnosis  implies  the  overcoming  of  a  considerable  dilliculty.  It  is 
true  that  by  the  elaboration  of  mechanical  aids,  and  liy  the  long 
training  of  the  senses,  it  is  possible  to  reduce  the  making  of  a 
diagnosis  under  certain  circumstances  to  a  very  simjile  and  a  \cry 
rapid  process.  Then,  however,  it  can  scarcely  any  longer  be  called 
diagnosis ;  it  has  become  recognition,  and  requires  very  little,  if  any, 
mental  effort.  In  dealing  with  antenatal  morbid  states,  it  is  diagnosis 
in  its  true  and  best  and  most  interesting  sense  that  is  needed.  There 
is  no  immediate  risk  that  any  one  w^ill  olitain  such  facility  in  the 
discovery  of  intrauterine  conditions  as  to  convert  antenatal  diagnosis 
into  a  dull  and  featureless  and  supremely  easy  procedure.  It  ought, 
therefore,  for  a  long  time  yet  to  retain  a  special  attraction  for  the 
diagnostician  who  rejoices  in  the  meeting  and  overcoming  of 
difficulties,  and  he  is  no  true  scientific  physician  who  does  not 
welcome  with  the  relish  of  the  epicure  the  truly  intricate  and 
obscure  prolilems  of  his  professional  work.  There  is  a  feast  ready  for 
him  in  Antenatal  I'athology. 

Medical  and  surgical  diagnosis  l)egaii  witli  the  separation  one 
from  another  of  the  external  morl)id  states  and  of  the  injuries  of  tiic 
limbs ;  after  many  centuries,  it  passed  to  the  investigation  of  the 
pathological  conditions  of  the  organs  contained  in  tlie  three  body 
cavities ;  and  while  some  still  alive  can  look  Imck  to  the  elaboration 
of  the  diagnosis  of  intrathoracic  and  of  intra-abdominal  diseases  and 
injtiries,  many  of  us  who  have  not  yet  become  old  in  the  profession 
regard  with  almost  personal  pride  the  development  of  intracranial 
diagnosis.  All  these  advanci's  Iiavc  meant  the  overcoming  of  many 
ditticultics,  some  of  them  not  inconsiderable,  some  of  them  at  first 


ANTENATAL   DIAGNOSIS  431 

sight  insuperable,  but  all  of  tiieui  yielding  before  the  active  brain  of 
man.  The  brain  itself  has  been  the  last  to  yield  up  its  secrets.  It 
is  now  full  time  that  an  energetic  and  sustained  effort  be  made  to 
carry  the  diagnosis  of  intra-abdominal  pathological  states  further 
than  it  has  ever  been  yet  taken.  The  task  is  difficult,  for  we  have 
to  investigate  the  condition  of  things  in  a  cavity  within  a  cavity ;  we 
liave  to  diagnose  not  merely  intra-abdominal  morbid  states,  but 
intrauterine  intra-abdominal  morbid  states.  The  difficulty  ought  to 
be,  indeed  it  is  all  the  stimulus  we  need. 

It  is  often  concluded  that  liy  antenatal  diagnosis  is  meant  the 
recognition  of  antenatal  morbid  states  during  antenatal  life  or 
intrauterine  existence — this  and  nothing  more.  The  definition  of 
antenatal  diagnosis,  however,  is  a  wider  one  than  that ;  for  by  it  are 
understood  the  recognition  and  the  separation  one  from  another  of 
all  the  pathological  conditions  which  are  produced  during  antenatal 
life,  not  only  while  that  period  of  existence  is  still  in  progress,  Ijut 
also  after  the  product  of  its  pathology  has  been  expelled  from  the 
uterus,  and  even  during  the  time  it  is  passing  through  the  vagina  on 
its  way  to  the  exterior.  The  birth  of  a  diseased  or  malformed  infant 
does  not  remove  the  necessity  for  a  diagnosis  of  its  particular  disease 
or  malformation,  nor  does  it  always  clear  away  the  difficulty  in 
making  it ;  even  if  the  child  be  already  dead,  it  will  be  for  the 
advantage  of  future  treatment  that  the  medical  man  make  out  the 
cause  of  death.  It  must,  therefore,  be  kept  constantly  in  mind  that 
the  diagnosis  of  antenatal  pathological  states  may  be  made  at  three 
times — during  antenatal  life  while  the  fo?tus  is  still  in  utero,  during 
the  act  of  parturition  or  intranatally,  and  after  birth  or  in  postnatal 
existence.  It  is,  of  course,  easier  to  make  the  diagnosis  intranatally 
than  antenatally,  and  much  easier  to  do  so  postnatally;  but  with 
decrease  in  difficulty  has  come  decrease  in  value,  and  the  chance  of 
successful  treatment  may  have  passed  away.  It  is  necessary, 
therefore,  to  give  the  first  place  to  the  discussion  of  antenatal 
diagnosis  made  dm-iug  antenatal  life,  as  well  on  account  of  its 
ditticiUty  as  of  its  value. 

Antenatal    Diagnosis. 

Emphasis  has  already  Ijeen  laid  upon  the  difficulties  of  diagnosing 
morbid  states  while  the  sulsject  of  them  is  still  in  utero,  and  it  is 
true  that  while  the  facilities  are  few  the  difficulties  are  many ;  liut  it 
must  not  be  forgotten  that  after  all  they  are  not  more  than  impedi- 
ments, they  are  not  insuperable  obstacles  to  the  making  of  a  diagnosis 
of  intrauterine  diseases.  Further,  can  the  medical  man  declare  upon 
"  soul  and  conscience  "  that  he  makes  in  every  case  of  pregnancy  that 
comes  under  his  care  a  full  and  searching  effort  to  remove  these 
obstacles  ?  It  is  not  that  he  does  nothing ;  he  listens  for  the  fietal 
heart,  he  notes  the  growth  of  the  uterine  tumour,  he  asks  about  the 
foetal  movements,  and  he  examines  the  maternal  urine  for  alliumen, 
not  once,  if  he  be  wise,  but  several  times.  But  he  is  content  with 
little;    he  is  satisfied  with  far  less  from  his   examination   of   the 


432  ANTRNATAI.    I'A'IIIOI.OCV    AM)    IIVCIKNE 

pregnant  woman's  alulonii'ii  tliaii  he  wmiM  lie,  for  insliint'L',  from  the 
investigation  of  licr  Inisljaiiil's  clicsl.  In  the  casu  of  an  obscure  lung 
com])laint  in  Uie  jircgnant  woman  herself,  this  same  medieal  man 
would  doubtless  pereuss  and  auscultate  and  palpate  the  thorax  till 
he  had  cleared  up  tlie  diagnosis,  and  would  feel  not  a  little  guilty 
and  ill  at  ease  if  he  failed  to  do  so ;  but  I  fancy  there  are  few 
])ractitiouers  who  would  pay  the  same  amount  of  attention  to  the 
examination  of  the  abdomen  and  uterus  if  the  patient  com])lained 
of  unusually  active,  or  unusually  inactive,  foetal  movements,  or  of 
acute  jiain  in  the  hypogastric  region.  In  surgery  and  in  medicine 
the  most  careful  and  searciiing  abdominal  palpation  is  not  infre- 
quently made,  and  with  good  diagnostic  efiect ;  but  for  some  reason 
a  similar  procedure  has  not  yet  become  common  in  obstetric  practice. 
Yet  it  is  precisely  in  obstetric  practice  that  it  is  most  called  for. 
There  can  be  no  doubt  that  in  antenatal  diagnosis  the  means  of 
clinical  investigation  at  our  disposal  are  seldom  made  full  use  of, 
and  are  too  often  nearly  completely  neglected.  It  may  lie  urged 
that  the  medical  man  has  little  or  no  oppoi-tunity  of  examining 
pregnant  women  in  such  a  manner  as  would  enable  him  to  form  an 
opinion  on  the  health  or  disease  of  their  unborn  infants ;  and  it  may 
further  be  stated  that  patients  do  not  offer  themselves  for  such  an 
exhaustive  examination,  and  even  refuse  to  allow  it  when  it  is  pressed 
upon  them.  Now,  for  this  state  of  affairs  the  meilical  jirofession  is 
largely  responsible ;  it  has  not  demonstrated  the  xoluv  of  such  a 
procedure,  and  it  cannot  be  expected  that  the  pulilic  will  follow 
where  the  profession  does  not  lead.  I  doubt  not  the  willingness  of 
the  pregnant  woman  to  sulimit  to  examination,  even  to  suffer  to 
some  extent  in  so  doing,  if  it  can  be  shown  to  her  that  she  is  thereby 
ensuring  her  own  welfare  and  that  of  her  unborn  infant. 

It  must  constantly  be  l)orne  in  mind  that  the  antenatal  diagnosis 
of  fretal  diseases  and  other  morbid  states  does  not  stand  on  the  same 
platform,  so  to  speak,  with  the  recognition  of  the  maladies  of  the 
adult.  There  is  something  special  in  it  and  peculiar  to  it.  In  many 
respects  it  resembles  rather  the  diagnosis  of  disease  in  the  new-born 
infant  than  in  the  child  or  adult.  Neonatal  diagnosis  is,  in  fact,  a 
sort  of  transition  between  antenatal  and  postnatal  diagnosis.  In  it, 
as  in  antenatal  diagnosis,  the  medical  attendant  has  to  learn  many  of 
the  facts  on  which  he  forms  his  opinion  from  the  statements  of  the 
mother  or  nurse,  and  in  his  jihysical  examination  of  the  infant  he 
pays  special  attention  to  its  movements,  attitude,  and  appearance, 
and  relies  much  upon  palimtion  and  auscultation.  He  does  not 
expect  to  get  any  answers  from  the  infant  of  the  verbal  sort,  and 
such  articulate  replies  as  he  elicits  may  hinder  rather  than  help.  So 
it  is,  only  in  a  more  marked  form,  with  antenatal  diagnosis.  Only 
now  the  inspection  of  the  infant  is  impossible,  and  the  physician  is 
thrown  back  still  more  >ipon  the  symptoms  of  tlie  mother  and  the 
palpation  of  the  foetus  still  in  her  uterus.  The  first  tiling  he  ought 
to  do  is  to  form  in  his  mind  the  visual  image  of  what  the  fotus  in 
utero  is  at  the  ascertained  or  conjectured  date  of  pregnancy.  At  first 
he  will  Hnd  it  difiicult  thus  to  imagine  his  little  unseen  patient,  but 


ANTENATAL   DIAGNOSIS  4:'.3 

practice  will  do  much,  and  he  will  eve  long  have  in  his  mind  the 
pictures  of  the  t'(etus  at  the  dittbrent  months  of  intrauterine  life, 
and  be  able  to  call  them  up,  as  it  were,  at  will.  He  will  find  it  ;■ 
great  help  to  read  over  a  description  of  the  outstanding  features  of 
the  foetus  at  the  different  stages  of  development  and  growth,  such  as 
is  given  him  on  ])ages  80  to  92.  He  will  doubtless  sympathise  not  a 
little  with  the  Western  physician  who  is  expected  to  diagnose  and 
treat  his  Eastern  female  patients  by  the  feeling  of  the  pulse  alone. 
Having  formed  the  visual  image  of  his  patient,  he  must  next  make 
up  his  mmd  to  give  more  weight  to  past  events  in  the  estimation  of 
present  conditions ;  in  other  words,  he  must  trust  to  the  tendency 
there  is  in  antenatal  disease  to  repeat  itself.  He  must  be  preparetl 
to  emphasise  factors  in  antenatal  wliich  are  little  dwelt  upon  in 
postnatal  diagnosis ;  and  altogether  he  must  be  ready  to  make  use  of 
every  scrap  of  evidence  which  he  can  obtain.  He  will  be  dis- 
appointed in  the  results  obtained,  but  he  must  not  be  discouraged. 
Finally,  he  must  remendjer  that  the  morbid  state  in  utero  may  be 
the  result  of  the  pathology  of  the  period  jireceding  the  fcetal ;  it  may 
be  a  monstrosity  or  malformation  which  has  been  carried  from  the 
embryonic  into  the  foetal  epoch.  I  shall  not  here  specially  describe 
the  diagnosis  of  monstrosities,  but  I  must,  of  course,  make  passing 
references  to  it.  Antenatal  diagnosis  includes  the  discovery  of 
normal  pregnancy  and  of  plural  pregnancy,  of  foetal  death,  of  diseases 
and  monstrosities  of  the  foetus,  of  hydramnios,  and  of  morbid  conditions 
of  the  placenta.  All  these  matters  must  be  kept  in  mind  in  examining 
a  patient  who  may  be  pregnant ;  and  in  all  of  them  there  is  at  any  rate 
an  increasing  probability  that  the  diagnosis  may  be  thoroughly  well 
estalilished  under  favouraljle  circumstances  and  with  care  and  skill. 

The  making  of  the  diagnosis  of  the  antenatal  morbid  state  during 
antenatal  life  will  best  be  accomplished  by  taking  up  the  following 
lines  of  investigation  in  order.  First,  the  previous  medical  history 
of  the  woman,  both  general  and  sexual,  must  be  inquired  into,  for 
there  are  certain  circumstances  which  may  be  regarded  as  commonly 
preceding  the  development  of  morbid  states  in  pregnancy ;  secondly, 
the  past  history  and  present  state  of  the  father,  and  the  family 
history  on  both  sides  ought  to  be  taken  into  account,  for  there  are 
foetal  diseases  and  embryonic  deformities  which  appear  to  be 
hereditarily  transmitted ;  thirdly,  the  maternal  symptomatology 
during  the  pregnancy  which  is  in  progress  must  be  carefully 
investigated  ;  fourthly,  a  very  complete  physical  examination  ought 
to  be  made  of  the  maternal  organs,  and  especially  of  the  abdominal 
viscera ;  fifthly,  the  foetus  should  be  fully  examined  by  the  liands,  by 
the  ear,  by  the  cephalometer,  by  the  Eiintgen  rays,  and  liy  any  other 
means  of  exact  research  that  may  yet  be  invented;  a,nd, fi,7ially,  the 
maternal  urine  and  blood  should  be  subjected  to  chemical  and  micro- 
scopical investigation,  as  it  is  beginning  to  be  realised  that  the  con- 
dition of  the  foetus  in  utero  is  to  some  extent  reflected  in  the 
composition  and  characters  of  the  maternal  excretions.  The  rest  of 
this  chapter  will  be  devoted  to  the  consideration  of  some  of  the 
diagnostic  possibilities  suggested  by  these  lines  of  research. 
28 


434  ANTENATAL    I'Al'l  lOl.OdV    AND    HYGIENE 

Maternal   Medical  History. 

Tlic  iiivesti;j;ati(iii  of  the  clinical  history  of  the  mother  of  a  still- 
born or  (lead-boru  or  diseased  or  deformed  infant  must,  in  the  first 
place,  deal  with  certain  purely  medical  questions.  The  hearing  of 
these  questions  upon  antenatal  morbid  ])rocesses  may  not,  in  the 
meantime,  he  very  evident ;  but  it  is  of  importance  in  a  subject  of 
such  comj)le.\ity  that  all  available  information  should  be  secured,  and 
in  other  branches  of  medical  diagnosis  the  physician  is  every  day 
learning  that  details,  at  one  time  considered  of  no  value  in  the 
etiology  of  maladies,  sometimes  take  on  a  sudden  and  preponderating 
importance — for  example,  the  pre-cancerous  phenomena.  Reference 
is  now  made  to  the  medical  conditions  of  the  mother  existing  prior  to 
and  apart  from  her  sexual  and  obstetrical  history,  and  the  question 
that  has  to  he  solved  is  whether  there  are  maternal  medical  states 
which  predispose  to,  or  at  any  rate  precede,  the  morbid  occurrences 
of  reproductive  life.  Are  there  any  facts  which  shall  enable  us  to 
predict  that  in  a  given  case  the  future  will  show  either  morbiparity 
or  monstriparity  or  mortinatality  ?  Can,  in  other  words,  a  typical 
past  medical  history  be  looked  for  in  the  mother  who  gives  birth  to 
diseased,  deformed,  or  dead  infants  ?  A  priori  it  may  be  exjx'cted 
that  women  who  have  had  a  healthy  childhood  and  girlhood,  who 
have  suffered  not  at  all  or  but  slightly  from  the  maladies  of  early 
life,  who  show  no  signs  of  rickets  or  of  congenital  syphilis  or  of 
anaemia,  and  who  are  not  the  victims  of  evident  cardiac,  pulmonary, 
hepatic,  renal,  or  nervous  disorders,  will  give  Ijirth  to  health)'  infants. 
On  the  other  hand,  it  may  be  expected  that  women  with  a  past 
medical  history  the  very  reverse  of  the  foregoing  will  produce  oil- 
spring  dead,  or  dying,  or  diseased,  or  deformed.  Now,  it  is  not 
difficult  to  find  cases  which  apparently  contradict  or  disappoint  these 
expectations,  for  perfectly  healthy  mothers  who  have  not  suffered 
from  severe  illnesses  in  early  life  give  birth  occasionally  to  deformed 
offspring,  and  delicate  and  diseased  mothers  sometimes  astonish 
every  one  Ijy  bringing  forth  strong  and  well-formed  infants :  lint  such 
instances  do  not  altogether  prove  that  the  past  medical  history  nf 
the  mother  is  of  no  importance  as  a  premonition  of  future  repro- 
ductive irregularities  ;  they  simply  remind  the  investigator  that  there 
is  a  second  factor  to  be  taken  into  accouut — the  state  of  health  of 
the  father.  But,  even  admitting  the  occurrence  of  contradictions  to 
the  expectation  that  a  woman  who  has  been  previously  healthy  iu 
other  ways  will  be  healthy  also  in  the  matter  of  reproduction,  the 
past  maternal  medical  history  ought  to  be  inquired  into.  1  have 
been  struck  on  several  occasions  by  the  frequency  with  which  women 
who  have  had  disastrous  obstetrical  histories  have  also  suftered 
previously  from  neuroses  of  various  kinds,  from  tubercle,  from 
alcoholism,  from  syphilis,  from  kidney  trouble,  from  rheumatism  and 
gout.  It  does  not  necessarily  follow  that  these  medical  conditions  of 
the  mother  prior  to  her  pregnancy  have  so  altered  the  ova  in  her 
ovaries  as  to  make  them  incajialile  of  healthy  development,  nor  does 
it  even  prove  that  her  whole  system  has  been  so  altered  as  to  be 


luii 


MATERNAL   HISTORY  435 

unable  to  react  in  a  healthy  fashion  ou  the  contents  of  her  uterus. 
It  may  be  taken  as  supporting  the  idea  that  both  the  morbiparity 
and  the  bad  medical  history  of  the  mother  are  results  of  a  common 
cause  ;  that  they  are  both  hereditarily  transmitted  to  her  ;  and  this  Is, 
I  think,  the  more  correct  way  of  looking  at  the  question.  Further, 
it  gains  support  from  the  fact  that  the  degenerative  conditions,  such 
as  nervous  diseases,  insanity,  arthritic  developments,  some  neoplasms, 
tubercidous  predisposition,  and  the  tendency  to  take  alcohol  and 
other  toxic  agents  to  excess,  are  apparently  governed  by  the  same 
laws  as  to  transmission,  etc.,  as  preside  over  malformations,  morbi- 
parity, mortinatality,  pluriparity,  abortions,  congenital  deljility,  and 
the  other  numerous  phenomena  of  antenatal  pathology.  They  show 
family  prevalence  very  markedly,  and  they  exhibit  the  form  of 
hereditj'  which  has  been  called  dissimilar.  This  association  between 
the  insanities,  the  nervous  diseases,  the  arthritisms,  the  tumours,  and 
the  morbid  phenomena  of  antenatal  life  has  been  strongly  insisted 
upon  by  Fere  in  his  most  suggestive  work,  La  Famillc  Ncrrojiuth  iqt'c,  to 
wiiich  reference  has  already  been  made  more  than  once  in  these  pages. 
It  will,  therefore,  be  of  the  greatest  importance  for  the  progress 
of  antenatal  pathology  for  observers  to  investigate  the  medical 
history  of  the  morbiparous  and  monstriparous  mothers  along  the 
lines  which  have  been  suggested.  So  far  as  my  own  observations 
have  proceeded,  they  tend  to  show  the  existence  in  the  mothers  of 
congenitally  malformed  or  diseased  infants  of  more  than  the  ordmary 
amount  of  manifestation  of  nervous  disease  and  even  of  insanity,  of 
arthritic  manifestations,  and  of  tubercle,  and  syphilis,  and  alcoholism. 
It  must  be  repeated,  however,  that  it  by  no  means  follows  that  all 
these  medical  states  are  the  causes  of  the  morbid  phenomena  of 
antenatal  Hfe.  Some  of  them  may  be  so ;  but  others  will  be  the  asso- 
ciated manifestations  of  a  common  cause  or  causes  which  appear  most 
e\'ideiitly  in  the  form  of  impaired  nutrition  of  the  tissues.  Neverthe- 
le,ss  their  presence  has  a  diagnostic  value  if  it  can  be  fully  established 
that  they  are  met  with  more  often  in  women  who  give  birth  to  dead 
or  still-born  infants,  to  diseased  or  malformed  foetuses,  to  twins,  or  to 
congenitally  weak  children. 

Maternal  Reproductive  History. 

The  mother's  pre\'ious  reproductive  history  is  of  much  more 
immediate  value  in  the  diagnosis  of  antenatal  morbid  states  than 
is  her  purely  medical  record.  Here  the  phenomena  are  closely 
associated  ;  they  are  to  a  certain  extent  manifestations  of  the  activity, 
physiological  or  pathological,  of  the  same  organs.  There  is  a  close 
connection  between  menstruation  and  ovidation  and  pregnancy ;  and 
there  is  a  very  close  connection  between  successive  pregnancies ;  for 
although  it  may  not  be  correct  to  say  "  ab  uno  disce  omnes,"  yet  there 
can  l^e  no  doubt  that  the  occurrence  of  one  alinormal  gestation  greatly 
increases  the  chances  of  the  supervention  of  others.  The  inquiry 
into  the  maternal  reproductive  history  may  be  made  along  the 
following  lines : — 


436  ANII'.NAIAl.    I'ArilOI.OCV    AM)    I  n(  ;i  I'.N  I'. 

1.  The  menstrual  habit  and  type  ouglit  to  be  aseertaineil,  unci  auy 
abnormal  conditions,  such  as  excessive  or  diminislied  How,  ])aiii,  etc., 
noted,  for  from  such  information  something  may  l)e  learned  of  the 
state  of  the  genital  organs  and  their  fitness  for  the  discharge  of  the 
reproductive  functions.  It  will  be  of  special  importance  to  elicit  tiie 
presence  of  symptoms  pointing  to  the  e.xistence  of  endometritis,  for 
it  is  well  known  that  a  diseased  uterine  mucous  membrane  predis- 
poses to  various  forms  of  antenatal  deviation  from  tlie  normal. 

2.  The  condition  of  the  mother  as  to  inarriaf/r  must  be  inquired 
into.  It  will  be  well  to  ascertain  whether  she  married  at  a  very 
early  age  or  late  in  life,  for  in  neither  of  these  circumstances  are  her 
pregnantdes  likely  to  be  normal.  Further,  the  fact  that  she  lias 
married  a  relative  such  as  a  cousin,  and  much  more  an  uncle,  must 
be  referred  to,  for  although  the  marriage  of  first  cousins  need  not  of 
itself  lead  to  abnormal  developments  during  ])regnancy  unless  the 
heredity  and  individual  health  on  both  sides  be  bad,  yet  the  fact  is  of 
importance ;  and  certainly  the  marriage  of  relatives  nearer  than 
cousins — for  e.Kample,  uncle  and  niece,  aunt  and  nephew,  would 
seem  to  produce  pathological  results. 

3.  The  history  of  the  previous  pregnancies  of  the  patient  may 
yield  information  of  the  very  greatest  value  in  the  making  of  a 
diagnosis.  As  case  after  case  of  antenatal  disease  or  disorder  has 
come  under  my  notice,  I  have  been  more  and  more  impressed  by  tlie 
tendency  of  abnormalities  in  pregnancy  to  repeat.  I  do  Udt  mean 
that  a  given  f(Etal  disease  or  embyronic  monstrosity  will  occur 
several  times  in  succession  in  the  uterus  of  the  same  jKitient, 
although  that  also  has  Ijcen  observed,  and  I  have  myself  noted  its 
occurrence  in  foetal  dropsy,  in  anencephaly,  in  Polydactyly,  in  tylosis 
palm;e  et  plauta?,  in  absence  of  the  radius,  etc. ;  but  I  refer  rather  to 
the  very  commonly  noted  fact  tliat  pregnancies  that  are  pathological — 
although  not  pathological  in  tlie  same  way — are  abuost  certain  to  be 
associated.  Over  and  ov'cr  again  there  is  the  liistory  of  aljortions, 
fietal  deatli,  fietal  disease,  still-birth,  congenital  debility,  twins, 
hydramnios,  malformations,  and  possibly  also  monstrosities,  in  the 
same  mother,  who  may  on  this  accoimt  be  called  morbiparous. 
Necessarily,  these  phenomena  do  not  often  all  occur  in  one  patient's 
history,  but  the  appearance  of  any  one  of  them  ought  to  prepare  us 
for  tlie  possible  supervention  of  any  other  of  them  in  a  future  preg- 
nancy. Further,  other  ])at]iological  events  of  rarer  occurrence  iniglit 
be  added  to  the  list,  sucli  as  the  hydatid  mole  and  extraulerine  and 
extra-amniotic  pregnancy.  Yet,  again,  it  is  wrong  to  think  that 
syphilis  is  the  only  morbid  state  that  determuies  this  long  series  of 
morbid  developments.  Alcoholism  at  least  does  so  also,  and  possibly 
tuberculosis,  lead-poisoning,  and  other  infective  and  toxic  and  toxi- 
cological  states.  Syphilis  and  alcoholism  oiler  a  striking  contrast,  in 
that,  while  the  antenatal  plienomena  of  the  former  tend  to  dimiiiisli 
in  virulence  as  the  reproductive  liistory  of  the  woman  jirogiesses, 
tliose  of  the  latter  morbid  condition  sliow  a  marked  tendency  lowartls 
intensification.  Enougli  lias  been  said  to  sliow  tiie  sui)renie  imjiort- 
ance  of  a  knowledge  of  the    mother's  previous  obstetric  history  in 


PATKRXAL   HISroUV  4o7 

forming  an  estimate  of  the  probable  character  of  the  gestations  (jf 
the  future,  and  it  is  unnecessary  to  do  more  than  refer  to  the  diag- 
nostic aid  that  may  be  received  from  the  record  of  previous  conKuc- 
ments  in  which  the  size  of  the  f(etus  or  its  malformed  or  diseased 
state  caused  delay  or  danger,  or  both,  or  in  which  it  was  noted  that 
the  placenta  or  membranes  were  abnormal  in  any  way.  So  well 
recognised  is  this  tendency  to  repeat  in  antenatal  pathology,  that 
the  terms  "  habitual  abortion,"  "  habitual  premature  labour,"  and 
"  habitual  fu'tal  death  "  have,  as  has  been  said,  been  used  to  express 
it;  but  a  more  correct  nomenclature  would  be  ''repeating  abortion," 
etc.,  for  the  idea  of  habit  is  scarcely  what  is  meant ;  and  we  ought 
to  look  not  so  much  for  the  repetition  of  identical  morbid  phenomena 
as  for  the  repetition  of  gestations  abnormal  in  some  way,  Ijut  not 
necessarily  in  the  same  way. 

Paternal  Medical  and   Reproductive   History. 

In  most  records  of  foetal  disease  and  monstrosity,  little  is  found 
.stated  with  regard  to  the  health  of  the  father.  This  is  unfortunate, 
for  it  seems  to  be  probable  that  paternal  morbid  states  acting  through 
the  spermatozoa  are  potent  in  inducing  antenatal  pathological  con- 
ditions. It  is  a  striking  comment  upon  this  line  of  inquiry,  that 
cases  ha^'e  been  reported  in  which  women  have  given  birth  to 
healthy  infants  by  one  husband  and  to  diseased  offspring  by  a  second 
consort.  I  have  myself  seen  several  cases  in  which  I  l:)elieve  I  was 
justified  in  tracing  to  the  father  the  origin  of  the  antenatal  malady 
or  deformity  of  the  infant ;  further,  the  condition  of  the  father  was 
not  invariably  syphilitic,  although  it  is  true  that  more  is  known  of 
the  paternal  factor  in  syphilis  than  in  any  other  morbid  state  which 
is  capable  of  transmission  to  the  ftetus.  It  is,  therefore,  necessary  to 
take  note  of  the  age  of  the  father  when  he  begets  his  child,  of  his 
age  in  relation  to  that  of  his  wife,  of  his  habits  especially  in  respect 
to  alcohol,  of  his  state  of  development,  and  of  certain  diseases,  such  as 
syphilis,  nephritis,  diabetes,  cancer,  tubercle,  malaria,  lead-poisoning, 
mental  disorder,  etc.,  from  which  he  may  be  suffering  or  have  suffered, 
for  there  is  good  reason  to  believe  that  any  of  these  pathological 
state.?  may  have  a  direct  and  injurious  effect  upon  the  offspring 
engendered  by  him.  It  may  also  be  that  the  morbid  paternal  influ- 
ence is  transmitted  directly  to  the  foetus  without  the  mother  suffering 
from  it  save  secondarily  through  the  foetus ;  this  is  believed  in 
respect  to  syphilis  {vide  p.  249),  and  there  is  some  evidence  that  it 
holds  also  for  malaria  (vide  p.  203),  and  probaljly  for  other  diseases. 
The  influence  of  paternal  alcoholism  has  not  yet  been  fully  worked 
out ;  but  one  of  the  striking  results  obtained  from  Sullivan's  contri- 
bution, already  referred  to,  was  that  total  abstinence  on  the  part  of 
the  father  did  little,  if  anything,  to  improve  the  prospects  of  the 
unborn  infant  so  long  as  there  was  still  maternal  alcoholism. 


438  AN'n.NATAl,    I' ATlIOLOCiV    AND    HYCilENE 

Family  Medical   History. 

In  rorining  a  iliagnosis  of  antenatal  morbid  states,  the  c)l)server 
cannot  allord  to  neglect  the  family  medical  and  obstetrical  history, 
for  such  conditions  are  not  infrequently  hereditary.  The  heredity, 
further,  may  not  always  be  of  the  same  kind.  Direct  and  similar 
heredity  is  sometimes  met  with,  and  when  it  occurs  it  is  so  striking 
tliat  it  seldom  passes  unnoted  ;  thus,  in  the  case  recorded  by  the  late 
Dr.  (!.  Klder  and  myself,  tylosis  palma-  et  plant;u  had  been  handed 
dowu  from  mother  to  daughter  and  then  to  granddaughter  antl  great- 
granddaughter  with  such  regidaritj',  that  it  was  expected  and  looked 
for  at  once  when  a  female  infant  was  born  into  the  family  {vide  p. 
318).  The  same  thing  has  Ijeen  noticed  in  anomalies  of  the  fingers 
and  toes,  and  especially  in  Polydactyly,  iu  congenital  cataract,  in 
retinitis  pigmentosa,  in  hare-lip,  in  cleft  palate,  in  fistuliu  of  the  lower 
lip,  in  n;cvi  materni,  iu  microphthalmus,  iu  aural  fistuLc,  and  in  a 
very  large  number  of  other  anomalies  and  congenital  diseases.  In 
other  phenomena  of  antenatal  pathology  the  same  tendency  is 
evident.  I  have,  for  instance,  given  striking  statistics  illustrating 
the  heredity  of  twin-bearing  and  of  large  families  (96),  and  the 
heredity  of  triplets  has  also  been  established  by  various  records.  Tlie 
following  case  I  cite  from  the  contribution  made  to  the  Ediulnirgh 
Obstetrical  Society  to  whicli  I  have  ju.st  referred,  ilrs.  I.  was  one 
of  a  family  of  seventeen  children,  and  one  of  her  sisters  has  had 
twins,  while  another  sister  has  had  triplets.  She  herself  has  had 
twenty-two  children  in  eighteen  confinements,  four  tiiues  twins  and 
fourteen  single  births.  The  first  contiuement  produced  a  boy  dead- 
born  ;  the  second,  twin  boys  at  the  si.xtli  month,  both  dead ;  the 
third,  a  boy,  dead-born  ;  the  fourth,  a  girl,  wlio  lived  six  weeks ;  tlie 
fifth,  a  boy  at  tlie  eighth  montli,  who  died  in  ten  days  from  umbilical 
hffimorrhage ;  the  sLxth,  a  boy  and  girl  at  the  sixtii  month,  dead-born ; 
the  seventh,  a  boy,  dead-born ;  the  eighth,  a  boy,  still  alive ;  the  ninth, 
a  boy,  died  in  sixteen  days  from  umbilical  haanorrhage ;  the  tenth,  a 
girl,  still  living,  aged  ten  years  ;  the  eleventh,  a  girl  at  full  term,  died 
shortly  from  convulsions ;  the  twelfth,  a  boy,  who  died  at  the  age  of 
one  year  from  wasting;  the  thirteenth,  a  boy,  who  died  at  six  weeks 
from  wasting ;  the  fourteenth,  a  girl,  who  died  at  eighteen  months 
from  whooping  cough;  tlie  fifteenth,  a  boy,  still  living;  the  sixteenth, 
twin  boys  at  the  sixth  month,  one  of  whom  alone  survived  his  liirtli, 
and  that  only  for  twenty-four  hours ;  the  seventeenth,  twins,  a  boy 
and  girl,  of  whom  the  girl  soon  died  from  wasting;  and  tlie 
eighteenth,  a  boy,  who  died  at  the  age  of  six  weeks. 

Of  course,  teratological  states  which  are  incompatible  with  extra- 
uterine life  cannot  be  transmitted  by  direct  and  similar  heredity; 
Imt  dissimilar  heredity  niay  and  dues  occur,  and  occasionally  a  jiarcnt 
with  a  luiuiir  malformation  whicli  iienuits  the  continuance  of  pro- 
longed postnatal  life,  procreates  a  feetus  with  a  monstrous  condition 
which  renders  it  quite  non-viable.  I  have  elsewliere  (117)  referred 
to  a  woman  with  malformed  thumbs,  the  daughter  of  a  woman 
similarly   deformed,   who   gave   birth   lo   infants   with    ancnceplialy. 


FAMILY    HISTORY  439 

hydrocephaly,  and  absence  of  radius  and  thumbs,  a  case  in  which 
there  was  both  similar  and  dissimilar  heredity.  Dissimilar  heredity 
also  is  very  common  in  antenatal  jjathology,  and  in  estimating  its 
presence  it  is  necessary  constantly  to  bear  in  mind  that  the  pheno- 
mena of  antenatal  pathology  are  not  confined  to  one  group  of  con- 
ditions such  as  malformations  or  ftctal  diseases,  but  include  also 
abortions,  twin  births,  mortinatality,  congenital  debiKty,  extrauterine 
pregnancy,  and  placental  and  membranous  abnormalities.  It  has 
sometimes  been  said  paradoxically  tliat  sterility  is  hereditary,  and  the 
statement  is  true  if  it  be  meant  tliat  a  woman  or  a  man  in  whose 
ascendants  (for  example,  in  aunts  or  uncles)  sterility  has  been 
common,  will  also  run  a  great  risk  of  being  sterile. 

In  the  family  history  of  niorbiparous  and  monstriparous  mothers, 
it  is  not  uncommon  to  find  a  morbid  predisposition  to  various  diseases 
developed  postnatally,  but  in  all  probability  present  potentially  before 
birtli ;  in  this  group  the  neuroses  find  a  prominent  place,  as  do  also 
susceptibilities  to  be  acted  on  abnormally  by  such  toxic  agencies  as 
alcoliol,  morphine,  and  tobacco. 

Maternal  Symptomatology. 

In  making  an  antenatal  diagnosis  of  morbid  intrauterine  condi- 
tions, the  closest  scrutiny  must  be  given  to  all  the  details  of  the 
pregnancy.  It  ought  to  be  our  object  to  elicit  from  the  mother 
all  that  she  can  remember  of  her  symptoms  during  both  the  early 
and  the  later  months  of  her  gestation ;  too  often  we  repress  such 
information,  partly  because  we  do  not  wish  to  make  the  patient 
nervous  about  herself,  and  partly  because  we  do  not  desire  to  hear 
long  tales  about  maternal  impressions.  Therein  doubtless  we  err ;  for 
although  the  mother's  s^^eculations  regarding  her  sensations  may  be 
worthless,  and  worse  than  worthless,  for  the  formation  of  a  diagnosis, 
the  same  cannot  be  said  of  tlie  definite  information  slie  gives  as 
to  the  occurrence  of  her  sensations.  Her  theoretical  opinions  may 
be  of  no  value,  but  her  statement  of  facts  is  of  great  imi^ortance ; 
we  must,  therefore,  endeavour  to  direct  her  flow  of  information  along 
the  line  of  facts,  and  not  in  the  current  of  theories. 

In  the  first  place,  we  inquire  into  the  symptomatology  of  preg- 
nancy itself,  for  it  is  not  altogether  a  truism  that  before  we  can 
diagnose  an  abnormal  i^regnancy  we  must  diagnose  that  there  is 
a  pregnancy.  Further,  the  very  ease  with  which  we  recognise  that 
there  is  the  normal  symptomatology  of  gestation,  is  indirect  evidence 
tliat  intrauterine  aSairs  are  progressing  in  a  natural  way ;  for  it  is 
the  abnormal  gestation  that  is  difficult  to  separate  from  conditions 
which  are  not  connected  with  the  presence  of  a  foetus  in  utero.  The 
very  fact  that  the  diagnosis  of  pregnancy  is  not  easily  made,  is  pre- 
sunipti\e  evidence  that  tliere  is  an  abnormal  pregnancy.  If,  then, 
it  Ije  found  that  in  the  history  of  the  case  the  symptoms  upon  which 
we  rely  in  diagnosis,  such  as  suppression  of  the  menses,  morning 
sickness,  frequency  of  micturition,  quickening,  mammary  fulness, 
nervous  phenomena  of  a  reflex  type,  abdominal  enlargement,  etc., 


440  AMI.N  AIM,    I'AllIOI.OC^     AM)    ll^(;ll.^l■. 

isliiiw  ilfvi:ilit)iis  which  make  us  dmilit  Lho  existence  of  pregnancy, 
we  may  ahiiost  unconscidusly  haxc  made  the  first  steji  in  the  diag- 
nosis of  a  case  of  antenatal  moiliid  change.  The  jiatient  herself  will 
often  sum  up  the  symiitomatology  for  us  in  the  remark  that  she  does 
not  feel  in  this  pregnancy  as  she  did  in  pievious  ones ;  that,  in  fact, 
she  doubts  if  she  is  really  "  in  the  family  way  "  at  all.  By  this  she 
generally  means  that  one  or  several  of  the  symptoms  u])on  which  she 
has  learnetl  to  rely  for  the  detection  of  pregnancy  have  deviated  so 
nnich  froiu  the  usual,  tliat  lier  o]iinion  has  been  sliaken,  while  tlie 
presence  of  other  of  these  symptoms  in  a  natural  way  lias  prevented 
her  altogetlier  abandoning  the  notion  that  she  is  jircgnant. 

Some  of  the  symptomatological  deviations  which  are  met  with 
may  be  referred  to.  There  is,  for  instance,  the  occurrence  of  more 
or  less  regular  and  more  or  less  sauguinolent  discharges  from  the 
vagina — the  persistence  of  menstruation  in  an  erratic  form.  In  the 
early  months  this  may  indicate  a  threatened  abortion  or  a  hydatid 
mole,  and  in  the  later  months  it  may  ])oint  to  a  low  implantation  of 
the  placenta,  or  to  premature  Separation  of  the  afterbirth.  It  may 
also  ])oint  to  the  existence  of  an  antenatal  morbid  condition  of  the 
uterus  itself,  such  as  a  bicornate  or  septate  organ,  (jr  t(j  the  presence  of 
a  tubal  or  tubo-abdominal  pregnancy.  Along  with  the.se  lutmorrhages, 
however,  there  is  a  continuance  of  the  other  phenomena  of  pregnancy, 
and  the  patient  becomes  alarmed  about  her  dubious  condition. 

It  may  be  stated  generally  that  we  do  not  yet  know  the  exact 
significance  of  irregular  menstrual  discharges  during  pregnancy,  and 
the  same  remark  applies  with  still  greater  force  to  the  occurrence 
of  hydrorrhoea  gravidarum.  P.  C.  T.  van  der  Hoeven  {Monaisschr.f. 
Geburtsli.  u.  Gyniik.,  x.  329,  1899)  has  given  details  of  three  cases  of 
hydrorrhcEa  in  pregnancy,  in  all  of  which  the  infants  were  born  alive 
and  liealthy,  but  premature,  and  from  the  chemical  and  microscopical 
examination  of  the  Huid  it  did  not  appear  that  it  was  either  liquor 
anmii  or  a  transudation  tlirough  the  membranes  from  the  liqufir 
amnii.  J.  A.  Macdougall  in  1885  gave  details  of  seven  cases  of  marked 
hydrorrhoea  gravidarum,  and  I  note  that  in  at  least  five  of  them  tiie 
fcctus  was  small,  puny,  and  poorly  develo]ied  {Edinh.  Med.  Journ., 
xx.x.  691,  1885). 

Again,  the  patient  may  complain  of  deviations  from  the  noinial 
in  the  symptomatology  of  quickenuig.  The  fa?tal  movements  may 
have  been  felt  very  early  or  unusually  late  in  pregnancy,  or  tliey 
may  have  been  very  strong  or  very  weak,  or  tiiey  may  have  been 
very  frequent  or  have  occurred  only  at  long  intervals,  or,  finally, 
they  may  have  shown  different  deviations  at  different  epochs  in  the 
gestation.  Sometimes  fa'tal  death  has  been  indicated  by  unusual 
activity  of  the  ftetal  movements,  followed  by  complete  cessation  of 
them.  In  cases  of  maternal  malaria,  the  mother  has  occasionally 
described  attacks  of  foHal  quivering  and  shaking  either  synchronous 
with  the  ague;  fits  in  herself,  or  occurring  at  otlier  but  at  regular 
times  (ride  p.  202);  it  has  been  concluded  that  there  was  fo'tal 
malaria,  but  not  always  of  the  same  ty])e  as  the  maternal.  Folal 
moNcments  of  a  kintl    very  different   from  the  normal  have  been 


I 


MATKHNAl.   SYMl'I'OMA  TOLOCY  441 

described  under  tiie  name  of  foetal  singultus.  The  details  of  a  case 
of  this  sort  were  communicated  to  me  some  time  ago  by  my  friend 
Dr.  T.  B.  Darling.  It  was  that  of  a  woman,  29  years  of  age,  a 
4-para,  who  had  in  each  of  her  four  pregnancies,  and  always  about 
the  seventh  month,  suffered  from  convulsive  movements  of  the  fcetus 
which  were  (juite  imlike  the  usual  "kicking"  sensations.  They 
were  regarded  bj'  her  as  due  to  hiccough  of  the  unborn  infant,  and 
they  occurred  most  markedly  at  night.  Her  belief  received  con- 
siderable support  from  the  fact  that  all  her  infants  suffered  from 
hiccough  for  a  few  days  after  birth,  and  that  the  movements  were 
very  similar.  It  is  interesting  to  note  that  in  tlie  first  two  preg- 
nancies the  vertex  presented  in  the  L.O.P.  position,  that  is,  with  the 
fcetal  abdomen  anterior ;  in  the  third  and  fourth  gestations,  however, 
the  position  was  the  E.O.A.  It  has  recently  been  affirmed  that  these 
peculiar  movements  are  not  very  rare,  although  it  is  likely  that  they 
are  not  often  so  marked  as  to  attract  special  attention  from  the 
mother  ;  liut  this  point  will  be  referred  to  again  under  the  head  of 
the  physical  examination  of  the  abdomen  in  pregnancy. 

Tlie  symptomatology  of  morljid  pregnancy  has  also  to  do  with 
abnormalities  in  the  degree  and  rate  of  abdominal  enlargement,  in 
the  mammary  sensations,  and  in  moining  sickness,  dysuria,  headache, 
neuralgia,  etc.  The  patient  may,  for  instance,  assert  that  she  is 
larger  or  smaller  than  she  ought  to  be  for  the  supposed  date  of 
pregnancy,  circumstances  which  may,  on  the  one  hand,  indicate 
hydramnios,  hydatid  mole,  twins,  a  dropsical  foetus,  a  double  monster  : 
and,  on  the  otiier  hand,  oligohydramnion,  poorly  developed  ftetus  or 
monstrosity  by  defect,  such  as  anencephaly.  Of  course,  it  may  mean 
nothing  more  than  that  she  has  made  an  error  in  her  estimate  of 
the  age  of  her  pregnancy.  Again,  she  may  state  that  she  has  a 
sensation  of  weight  or  of  coldness  in  the  lower  part  of  the  alxlomen, 
that  the  al;idominal  enlargement  has  ceased  to  grow,  that  the  breasts 
have  stopped  swelling,  and  that  certain  neuralgias  or  other  reflex 
phenomena  which  she  has  come  to  ass(jciate  with  tlie  continuance  of 
gestation,  have  ceased ;  and  from  these  symptoms  she  may  draw  tlie 
conclusions  that  the  fa3tus  in  utero  has  died,  and  it  may  very  well  l)e 
that  she  is  quite  right  {vide  p.  416). 

In  the  second  place,  we  must  inquire  into  the  spuptoms  which 
have  been  present  in  pregnancy  which  have  nothing  to  do  with 
pregnancy  as  pregnancy.  For  instance,  she  may  have  suffered  from 
an  infectious  fever,  and  have  had  its  typical  symptoms,  or  she  may 
simply  have  been  exposed  to  the  infection  without  herself  showing 
its  manifestations.  It  does  not,  of  course,  follow  that  the  diagnosis 
of  foetal  infection  can  be  certainly  made  under  such  circumstances ; 
but  it  makes  it  a  probabilitj',  and  it  ought  also  to  make  the  observer 
think  of  foetal  death,  of  premature  labour,  and  of  congenital  weak- 
ness, or  other  indication  of  toxinic  poisoning  of  the  unborn  infant. 
Fm-ther,  there  is  evidence  that  an  infectious  condition  in  the  mother 
may  be  connected  with  an  apparently  entirely  different  morbid  state 
in  the  foetus,  as  in  Bidone's  case  of  erysipelas  in  the  mother  with 
streptococcic  endocarcUtis  in  the  fcetus  {vide  p.  198),  or  in  Moucorvo's 


442  ANTEXATAI.    I'ATIIOLOCY    AM)    I1Y(.11:NR 

record  of  repeated  lyiiipliaiiiiilis  in  the  niutlier  a.s  tlie  result  of  trau- 
matism, with   infection  and   congenital  eleiihaiitiasis   in   the   infant   f 
(vide  p.  :>02).      Although   aijjjarently   unconnected,  the   fictal   state    !• 
may  nevertheless  be  the  result  of  the  maternal  infection,  for  allow-    ;• 
ances  must  be  made  for  differences  in  environment  and  in  idiysiology,   1 
Reference  may  here  be  made  to  the  occurrence  of  traumatism  in    ^ 
pregnancy :  this  should  always  be  noted,  for  it  may  have  a  direct   \ 
bearing  upon  fietal  injuries,  death,  and  even  deformities.    Here  also  it    j: 
may  be  well  that  maternal  imjiressions  Ijc  rei'orded,  and  their  nature    \ 
and  the  date  of  gestation  at  which  they  took  jilace  noted,  if  for  no    ' 
other  purpose  than  to  disprove   the  efficacy  of  these  imjjressions  in 
the  jH'oduction  of  monstrosities.     Further,  the  fact  that  the  nu)tluT 
during  her  pregnancy  has  had  for  any  reason  to  take  powerful  or 
poisonous  drugs  ought  to  be  referred  to  in  the  formation  of  a  diag-    4 
uosis  of  fa?tal  disease  or  death ;  the  toxicology  of  intrauterine  life  is  a   || 
large  and  as  yet  almost  unworked  field  (cidc  ]>.  Ii58).     The  commence-   ' 
ment  or  continuance  of  habits  of  intemperance  during  the  gestation    . 
must  1)6  noted  ;  and,  finally,  the  supervention  of  symptoms  of  disorder 
in  any  of  the  great   systems,  such   as   the  circulatory,  resjiiratory, 
digestive,  urinary,  cutaneous,  or  nervous,  must  not  be  passed  over,      ^ 
for  such  may   throw  light,  often  quite  unexpectedly,  upon   morbid 
intrauterine  states. 

It  may  be  that  in  this  enumeration  of  the  symptoms  of  morbid 
gestation  I  have  referred  to  conditions  which  have  little  apparent 
diagnostic  value,  but  the  antenatal  pathologist  is  not  yet  in  a  position 
to  say  what  is  and  what  is  not  of  importance  in  this  matter.  It  is 
only  by  the  careful  recording  of  all  such  circumstances  that  he  can 
ever  hope  to  build  up  a  system  of  fcetal  symptomatology.  If  the 
truth  be  told,  it  is  not  excess  of  zeal  in  recording  the  phenomena 
of  morbid  pregnancies  that  is  to  be  deplored  or  feared,  liut  the 
reverse. 

Maternal  Physical  Examination. 

After  the  history  and  symptomatology  of  the  pregnancy  have 
been  ascertained,  it  will  be  necessary  to  proceed  to  an  exhaustive 
physical  examination  of  the  maternal  and  fietal  organisms,  and  iu 
the  case  of  the  mother  it  will  be  important  to  examine  not  only  the 
reproductive  (jrgaus,  but  also  the  other  bodily  systems. 

1.  Physical  examination  of  the  maternal  circulatory,  respiratory, 
and  other  systems  (except  the  reproductive).  The  discovery  of  a 
serious  diseased  condition  of  any  of  the  maternal  systems  does  not, 
of  course,  enal)le  the  observer  to  declare  that  the  fietus  is  suHeriug 
in  the  same  organ,  and  in  the  same  wa}-.  Antenatal  diagnosis 
is  not  so  easy  as  that.  At  the  same  time,  it  makes  it  possible, 
and  with  some  maladies  even  probable,  that  the  fcrtus  is  affected 
with  the  same  pathological  change  as  the  niollicr.  .iiid  it  nearly 
always  enables  the  observer  to  predict  that  tlic  infant  unlnun  is 
suHering  in  some  way  or  other,  and  that  the  jircgnancy  will 
be  in  some  way  lU'  other  abnormal.  The  structures  in  the  uterus 
do  not  retlect,  as  in  a  mirror,  the  state  of  the  maternal  organs; 


MATERNAL    PHYSICAL   EXAMLXATION  443 

but  it  is  (loulitful  whether  there  can  he  anything  far  wrong  with  the 
mother's  economy  without  the  tVetus  or  embryo  sutt'ering  in  one  way 
or  another,  and  it  occasionally  happens  that  it  sutlers  in  the  same 
way.  For  instance,  the  discovery  of  grave  maternal  cardiac  disease 
(namely,  a  state  of  mitral  incompetence  anil  stenosis  of  recent  origin 
and  without  compensation)  will  be  an  undoubted  warning  that 
aliortion,  or  prematnre  labour,  or  fcctal  death  may  be  looked  for; 
and  it  may,  especially  when  the  maternal  valvular  lesions  can  be 
traced  to  acute  rheumatism,  mean  that  the  infant  will  be  born  witli 
a  malformed  heart,  and  possibly  with  a  murmur  caused  thereby. 
Again,  the  existence  of  pulmonary  tuberculosis  does  not  often  carry 
with  it  phthisis  of  the  fa?tus,  or  even  evident  tuberculous  changes  in 
any  of  the  organs  or  in  the  placenta  ;  but  it  may  and  often  does  carry 
■with  it  deviations  from  the  normal  progress  of  gestation,  such  as 
premature  delivery,  and  the  infant  may,  as  has  been  pointed  out  by 
Hanot  and  others,  show  malformations — for  example,  stenosis  of  the 
pulmonary  artery  {vide  p.  215).  Septic  pneumonia  of  the  mother 
may  occasionally  produce  septic  pneumonia  of  the  fo?tus ;  it  cannot 
be  doubted  that  it  nearly  always  interferes  in  some  way  with  the 
pregnancy  which  it  compUcates.  Similarly  renal  mischief  in  the 
motiier  produces  changes  in  the  fa?tal  tissues,  which  are  sometimes 
localised  in  the  kidneys,  but  more  often  are  found  in  the  other 
organs,  and  very  often  in  the  placenta,  which  is,  after  all,  the  kidney 
of  the  unliorn  infant.  Marked  maternal  dropsy  often  means  simply 
placental  lesions  and  a  puny,  badly -nourished  fa-tus ;  Init  sometimes  the 
t'cEtus  when  Ijorn  sliows  general  anasarca ;  out  of  06  cases  of  marked 
fietal  dropsy  there  was  also  maternal  dropsy  in  16  (vide  p.  290). 

After  ha-\-ing  examined  the  maternal  circulatory,  respiratory,  and 
urinary  systems  (I  omit  for  the  present  a  reference  to  the  testing  of 
the  urhie),  the  observer  should  turn  his  attention  now  to  the  other 
systems.  Tiie  osseous  and  locomotor  structures  should  be  examined, 
for  women  with  achondroplasia  have  given  birth  to  achondroplasiac 
infants ;  and  congenital  rheumatism,  although  rarely  recognised,  has 
now  and  again  been  noted  in  the  offspring  of  mothers  who  have 
suffered  from  rheumatic  fever  in  pregnancy.  Nervous  diseases,  in 
addition  to  being  distinctly  hereditary,  produce  effects  in  other  ways 
upon  the  products  of  conception.  Goitre  in  the  mother  has  some- 
times been  found  in  her  foetus,  and  Demme  of  Berne  found  that  in 
53  cases  of  congenital  goitre  37  had  mothers  suffering  from  the  same 
malady  {ride  \>.  376). 

The  physical  examination  of  the  mother  must  include  the  search 
for  congenital  anomalies  in  herself,  such  as  uajvi,  minor  malformations, 
and  muscular  peculiarities,  for  such  are  now  and  again  to  be  expected 
in  lier  infant.  It  must  include  the  taking  of  her  temperature  and 
the  inspection  of  the  skin,  for  in  nearly  all  the  infectious  maladies, 
such  as  smallpox,  scarlet  fever,  typhoid,  measles,  varicella,  and  ery- 
sipelas, the  possibility,  and  indeed  the  strong  probability,  is  that 
there  is  a  transmission  of  the  morljid  agency  thi'ough  the  placenta 
to  the  ftetus,  with  results  which  may  not  always  exactly  resemble 
those  existing  in  the  mother,  but  which  are,  nevertheless,  due  to 


444  ANll'.NAl'AI,    I' AlllOI.OdV    AM)    1  n(.l  I'.N]'. 

LliL'iii.  Jiuiiiilicc  ill  iiiotliuL-  and  fcctus  has  been  noted,  so  has  hiunior- 
rliagir  purimia,  so  has  epidemic  cerebro-spinal  meningitis.  Even  if 
the  fd'tus  esc.ai)e  the  disease  in  its  oidiiiaiy  manifestations,  it  may 
fall  a  victim  to  the  increased  maternal  temperature ;  or  the  toxins 
arriving  in  the  placenta  may  cause  disease  of  that  structure,  or  may 
pass  on  to  the  fu-tus  and  cause  pathological  changes  in  it. 

Tiiere  is  another  aspect  to  this  subject.  It  is  possible,  and  indeed 
probable,  tiiat  morbid  states  in  the  fcetus  may  cause  changes  in  the 
maternal  organs  which  are  capable  of  being  recognised  liy  the  observer. 
P\ctal  death,  for  instance,  may  be  followed  liy  tiie  disappearance  of 
varicose  veins,  by  shrinking  of  tlie  thyroid  enlargement,  and  liy  a 
freer  condition  of  respiration ;  when  the  hrtal  death  is  accompanied 
by  putrefactive  changes  in  utero,  maternal  vomiting,  hectic,  high 
temperature,  and  other  signs  of  lilood-poisoning  will  occur.  It  is 
also  very  probable  that  a  diseased  fcetus  may  react  u])on  the  maternal 
system;  but  this  is  a  matter  upon  which  we  have  little  information, 
and  the  cases  which  might  teach  us  something  about  it — such  as 
instances  of  fcetal  small^jox  in  an  immune  mother — are  very  rarely 
noted.  At  the  same  time,  there  is  reason  to  believe  that  a  high  tem- 
perature in  the  fcetus,  with  excess  of  waste  products  passing  to  the 
placenta,  and  so  into  the  mother's  system,  may  sometimes  determine 
eclampsia,  or  albuminuria  at  least. 

2.  Physical  examination  of  the  maternal  reproductive  system.  It 
goes  almost  without  saying  that  in  diagnosing  intrauterine  conditions 
it  must  be  from  the  examination  of  the  uterus  and  its  contents  that 
the  facts  of  the  greatest  value  will  be  obtained.  The  examinaticjn  of 
the  maternal  organs  of  generation  now  falls  to  be  considered. 

The  insiiection  and  palpation  of  the  mammary  glands  may  reveal 
retrogressive  changes  wliich  point  to  fcetal  death;  so  may  the  fading 
of  the  purple  discoloration  of  the  vulva  and  vagina.  The  ins])C"C'tion 
of  the  abdomen  may  show  at  a  glance  that  it  is  larger  or  smaller  than 
tlie  calculated  age  of  the  pregnancy  warrants  it  being,  and  this  obser- 
vation may  be  corrected  and  confirmed  by  careful  mensuiatidii. 
Periodic  mensurations  may  show  that  the  alxlomen  is  not  enlarging 
in  a  steady  fashion,  or  is  not  enlarging  at  all.  Palpation  may  dis- 
cover a  uterus  more  cystic  in  feeling  than  is  normal  in  gestation,  a 
circumstance  which  will  suggest  hydramnios,  or  may,  indeed,  cast 
grave  doubts  upon  the  existence  of  pregnancy  at  all.  Here  it  may 
again  be  said  that  when  we  are  in  doubt  about  the  existence  of 
])regnaney,  it  will  be  well  for  us  to  suspect  the  existence  of  an 
abnormal  pregnancy.  I'ercussion  of  the  aljdomen  may  serve  to  mark 
out  more  clearly  the  uterine  outlines  and  to  eliminate  pseudocye.sis 
from  the  diagnostic  possibilities ;  and  auscultation  may  make  known 
irregularities  of  the  uterine  .so^/Z/c,  iwinting  to  anomalies  in  the  growth 
of  the  uteru.s. 

Physical  Examination  of  the   FcEtus  in   Utero. 

The  physical  examination  of  the  imborn  infant  can  hardly  he 
separated  from  that  of  the  mother's  uterus  and  vagina,  either  iu 


I'fnSUAI.   EXAMINATION    OF   Till',   Fd'.TLTS  445 

tlieory  or  practice.  As  a  matter  of  fact,  the  two  procedures  are 
carried  on  simultaneously. 

Abdominal  iuspection  can  scarcely  do  more  than  suggest  that  tlie 
foetus  is  very  large  or  very  small,  or  not  alone  in  utero;  abdominal 
palpation,  on  the  other  hand,  may  be  made  a  diagnostic  means  of  the 
greatest  importance  and  value.  Nowadays,  when  so  much  stress  is 
laid  upon  the  recognition  of  presentations  and  positions  by  abdominal 
without  vaginal  manipulation,  it  must  follow  that  obstetricians  will 
feel  better  able  to  appreciate  deviations  from  the  normal  in  the  size 
and  form  of  tlie  tVetus.  Further,  the  widening  of  practice  in  the 
sphere  of  alidominal  sixrgery  must  have  given  most  of  us  a  more  dis- 
tinctly erudite  touch  than  we  ever  possessed  before.  It  is  largely,  I 
believe,  want  of  utilisation  of  our  powers  in  this  respect  that  has 
interfered  with  the  more  frequent  making  of  an  antenatal  diagnosis. 
Let  us  examine  the  abdomen  of  the  gravid  woman  with  the  same 
care  that  we  would  employ  if  we  were  anticipating  the  performance 
of  an  o\'ariotomy  or  a  hysterectomy.  Further,  let  us  not  forget  to 
use  both  hands,  either  both  outside  the  abdomen,  or  one  outside  and 
the  other  inside  the  vagina,  in  order  to  get  the  help  which  the 
bimanual  method  always  gives.  Antesthesia  may  yield  as  valuable 
results  in  the  examination  of  the  foetus  in  utero  as  in  any  other 
department  of  medical  practice ;  and  there  are  some  emergencies  in 
antenatal  pathology  which  fully  justify  us  in  putting  the  mother 
under  chloroform. 

By  abdominal  palpation,  either  with  or  without  anrestbesia,  it 
may  be  possible  to  make  out  the  irregular  foetal  outhnes  and  the 
indistinct  crepitus  associated  by  Negri  {Aim.  di  ostct.  e  f/inec,  v.  82, 
1883 ;  vii.  223,  1885)  with  fcetal  death,  to  diagnose  provisionally  that 
there  are  twins  in  utero  or  a  double  monstrosity,  to  ascertain  the 
presence  of  excess  or  of  scantiness  of  liquor  aumii.  and  possibly  also 
to  hazard  the  speculation  that  the  fiptus  is  small,  or  large,  or  grossly 
malformed.  Peculiarities  in  the  fcetal  movements,  such  as  their 
great  strength,  or  frequency,  or  character  (for  example,  singultus), 
may  be  detected  by  the  hands,  and  tiie  difficulty  or  ease  with  whicli 
laliottcmcnt  can  be  elicited  has  a  diagnostic  value.  In  cases  of 
hydramnios,  where  it  is  usually  very  difficult  to  palpate  the  fcctus, 
and  where  it  is  particularly  important  to  be  alale  to  do  so,  it  has  been 
recommended  to  put  the  patient  in  the  genu-pectoral  position,  so  as 
to  allow  the  foetus  to  gravitate  towards  the  abdominal  i)art  of  tlie 
utei'us,  where  it  can  be  better  felt ;  but  care  must  be  taken  that  the 
mother  does  not  faint  or  have  very  grave  dyspncea  during  the  pro- 
cess, and  I  fancy  the  same  result  in  aiding  palpation  will  be  obtained 
by  putting  the  patient  on  the  side  or  in  the  .semi-prone  position. 
An  unusually  cystic  feeling  in  uterus,  with  the  existence  of  tiie  other 
symptoms  and  signs  of  jiregnancy,  ought  to  make  the  observer  suspect 
hydramnios,  and  along  with  it  a  monstrous  condition  of  the  uterine 
contents  or  the  presence  of  twins ;  for  if  there  is  one  fact  in  antenatal 
pathology  that  is  well  established,  it  is  the  association  of  teratological 
conditions,  twinning,  and  hydramnios.  The  scarcity  of  the  hquor 
amnii  is  also  a  sign  of  intrauterine  morbid  changes,  especially  of 


446  ANTI'.N  Al'AI,    I'MIIOLOC^'    AM)    IIV(iIENE 

lauUiplc  malformations,  congenital  dislocations,  fractures,  and  anky- 
loses. Doubtless  in  tlie  future  the  palpation  of  the  foetus  in  utero 
will  be  much  more  widely  ])ractiseil  than  it  has  Ijeen  in  the  past. 

Auscultation  of  the  abdomen  to  detect  the  presence  of  tlie  fcetal 
heart  is  a  common,  indeed  a  constant,  jn-actice  with  the  careful  ) 
obstetrician,  but  there  seems  to  be  no  doubt  that  the  ol)servant  ear  ■ 
ought  to  be  able  to  make  out  more  from  tliis  method  of  investigation 
than  the  diagnosis  of  pregnancy.  Some  years  ago,  a  colleague  .showed 
me  some  daily  estimations  of  the  f(i>tal  heart-rate  taken  by  liimself 
in  the  case  of  Ids  pregnant  wife:  he  liad  made  them  with  the  liope 
of  arriving  at  a  conclusion  regarding  the  sex  of  his  unborn  child,  and 
hia  method  had  been  to  make  d(jts  with  a  pencil  on  paper  as  he 
listened  over  the  abdomen  with  the  stethoscope  for  a  period  of  half  a 
minute  or  a  minute,  as  determined  for  him  by  the  patient.  The  pro- 
cedure was  a  little  difficult,  but  it  struck  me  at  the  time  tliat  it  had 
possibilities  in  it  which  could  scarcely  lie  overestimated ;  it  might, 
for  instance,  be  valuable  in  giving  warning  both  of  disease  and  of 
impending  death  in  the  fietus,  and  it  migiit  be  i;sed  as  a  clinical 
means  of  determining  what  drugs,  when  given  to  the  mother,  pa.ssed 
through  the  placenta  and  produced  a  pharmacologicid  effect  ujion  the 
infant  in  utero.  In  a  recent  case  of  pregnancy  which  was  under  my 
charge  during  1899,  I  was  impressed  by  the  fact  tliat  the  mother,  a 
primipara,  who  had  not  lieen  strong  during  girlhood  (threatened  hip- 
joint  disease),  during  the  latter  half  of  gestation  rajiidly  juit  on  flesh 
and  weight ;  synchronous  with  this  improvement  in  the  maternal 
condition,  there  was  a  markeil  slackening  in  the  growth  of  the  fcetus 
and  a  weakening  and  slowing  of  the  fcetal  heart,  with  an  almost 
entire  absence  of  fn:>tal  movements ;  it  seemed,  to  put  it  into  ordinary 
language,  as  if  the  mother  were  being  nourished  at  the  expense  of 
the  offspring.  At  any  rate,  I  diagnosed  a  small  infant  with  very 
little  liquor  amnii  and  possible  placental  changes.  I'he  event  proved 
me  to  be  right,  for  tlie  infant — a  male- — was  puny  and  had  a  senile 
appearance,  was  In'ought  tlu'ough  the  first  weeks  of  life  only  with  the 
greatest  care  ;  and  the  placenta  was  small,  of  the  marginate  variety, 
and  diseased ;  there  was  scarcely  any  liquor  amnii. 

The  character  of  the  foetal  heart  sounds  may  also  give  diagnostic 
indications,  and  the  number  of  cases  in  which  fwtal  heart  disease  or 
malformation  was  found  out  before  birth  is  every  year  lieing  added 
to.  Within  the  past  few  years,  liellot,  Padgett,  Nazarofl',  and  Hall 
have  all  diagnosed  fu'tal  heart  mtu'murs,  and  confirmed  the  diagnosis 
after  the  infant  was  born  (vide  p.  372).  Hall  in  his  cmnnnuiication 
gave  details  of  cases  by  Earth,  Hennig,  and  Christopher;  in  tlie 
example  reported  by  himself,  the  lesion  seemed  to  have  been  a 
roughening  of  the  lining  membrane  of  the  ductus  arteriosus,  for  the 
murmur  which  affected  tlic  tirst  sound  disappeared  ten  days  after 
birth.  It  has  been  affirmed  liy  Giglio  {Ann.  di  osfet.  c  i/mec,  xix.  333, 
1897)  that  the  presence  of  an  anencephalic  fcetus  in  utero  may  be 
suspected  from  the  weak,  uncertain,  distant,  and  frequent  lieat  of  the 
heart,  characters  winch  may  be  due  to  the  absence  of  cerebral  and 
spinal  centres  having  to  do  witli  the  innervation  of  the  heart.     In 


PHYSICAL   EXAMINATION    OF  THE   FOETUS  447 

such  cases,  and  on  account  of  the  above-named  peculiarities  of  the 
fcotal  heart-beat,  it  is  often  supposed  to  he  absent  unless  very  care- 
fully listened  for ;  this  apparent  absence,  when  associated  with  active 
ftctal  movements  (and  with  signs  of  hydramnios),  may  point,  there- 
fore, to  anencephaly. 

The  absence  of  the  foetal  heart  sounds,  especially  in  a  case  where 
they  have  been  previously  well  heard,  and  in  which  their  disappearance 
has  been  preceded  by  a  slowing  of  them,  points  strongly  to  foi'tal 
death ;  but  it  must  always  be  remembered  that  absence  of  the  fcetal 
heart  is  a  negative  sign,  and  therefore  never  of  the  same  diagnostic 
importance  as,  for  instance,  presence  of  it  is  in  the  estimation  of 
pregnancy  and  fretal  life  (vide  p.  417). 

Other  sounds  in  utero  detected  by  the  stethoscope  have  been 
referred  to  by  authors.  Thus  bubbling  sounds  due  to  intrauterine 
decomposition,  and  alterations-  in  the  uterine  or  placental  souffle  have 
been  described  in  cases  of  ftetal  death  ;  but  their  diagnostic  value  is 
most  problematical.  It  seems,  however,  that  the  early  fcetal  move- 
ments may  be  heard  even  Ijefore  they  are  felt. 

Mensuration  of  the  fwtus  in  utero  is  a  well-known  means  of 
forming  an  idea  of  the  age  of  the  pregnancy,  especially  in  connection 
with  the  induction  of  premature  labour ;  but  it  is  a  method  which 
seems  to  have  been  Uttle,  if  at  all,  employed  in  the  diagnosis  of 
anomalies  in  the  size  and  form  of  the  unborn.  It  may  be  carried  out 
with  the  aid  of  a  pair  of  callipers,  or,  better,  with  the  special  modi- 
fication of  them  known  as  the  eephalometer  of  Bndin  and  Perret 
{L'Ohstdtnquc,  iv.  542, 1899);  by  means  of  this  instrument,  which  I  have 
employed  by  preference,  certain  of  the  fcetal  cranial  diameters  have 
been  determined  with  a  degree  of  error  rai'ely  amounting  to  more  than 
5  mm.  There  is  no  reason  why  this  instrument  should  not  be  used  for 
the  detection  of  abnormalities  in  head  and  body  measurements. 

The  graphic  representation  of  the  foetal  movements  is  another  way 
in  which  mechanical  methods  may  be  made  to  help  the  obstretrician 
in  his  attempt  to  find  out  the  state  of  the  unborn  infant.  Fa?tal 
movements  are  chiefly  of  four  kinds :  revolutionary  ;  extensions  and 
flexions  of  the  limbs ;  extension  and  flexion  of  the  spine,  especially  of 
the  cervical  part  of  it ;  and  rhythmical  movements  of  the  trunk,  and 
particularly  of  the  thorax,  which  have  been  ascribed  to  fo?tal 
singultus,  to  swallowing,  and  to  intrauterine  respiration  {vide  p.  169). 
These  movements,  as  also  the  fcetal  heart-beat,  maybe  represented  as 
tracings  by  the  ordinary,  although  slightly  modified,  apparatus  known 
as  the  cardiograph.  Pestalozza,  in  a  case  of  twins,  succeeded  in 
getting  a  tracing  of  the  foetal  heart,  but  the  conditions  were 
peculiarly  favourable,  and  not  likely  soon  to  occur  again  {vide  p.  137). 
Ferroni,  however,  has  shown  that  it  is  quite  feasible  to  get  good 
tracings  of  the  two  kinds  of  rhythmical  movements  which  have  been 
ascribed  to  fcetal  singultus  and  to  respiration,  the  former  being 
abrupt,  with  an  apex,  and  of  a  rate  of  from  fifteen  to  thirty-four 
per  minute,  the  latter  being  undulatory,  without  interruptions,  and 
at  a  rate  of  from  forty  to  seventy  per  minute  {vide  p.  144).  Ferroni 
also  got  fcetal  tracings  in  a  case  of  maternal  typhoid  and  in  another 


448  ANTl'.N  A  TAI.    I'A  11 1( )!,()( I")     AM)    IHCIKXE 

of  malaria.  There  is  some  justiticatioii  for  the  liope  and  expectation 
that  ere  long  this  method  of  investigation  of  the  infant  in  utero  may 
be  expanded  and  made  of  use.  Wlien  it  is  home  in  mind  how  much 
we  can  learn  from  the  movements  and  attitude  of  the  new-horn  and 
young  infant,  there  is  surely  reason  for  trying  to  learn  something 
about  these  same  movements  and  attitude  in  the  IVrtus.  It  is  a  fact, 
but  not  perhaps  a  recognised  fact,  that  the  symptoms  and  signs  of 
disease  in  the  fu'tus  will  more  closely  resemble  those  of  the  infant 
than  those  of  tlie  adult  or  child. 

Skiagraphy  will  no  doidjt  also  play  a  part,  perhaps  not  an 
unimportant  part,  in  tlie  antenatal  diagnosis  of  the  future,  but  in  the 
meantime  the  results  obtained  by  Varnier  (Ann.  de  gyiu'c,  li.  278, 
1 899)  have  been  exceedingly  unsatisfactory  as  regards  tlie  foetus.  For 
this  failure  various  riiasons  are  forthcoming.  Among  these  may  be 
named  the  deep  shadow  thrown  by  the  mother's  iielvis  and  sjiinal 
column,  the  imperfectly  ossified  f<i'tal  skeleton,  the  thickness  of  the 
maternal  structures,  the  imiiossibility  of  getting  the  sensitive  plate 
in  the  same  relation  to  the  abdominal  and  pelvic  part  of  the  pregnant 
uterus,  and  perhaps  the  respiratory  maternal  and  the  irregular  fo>tal 
movements.  To  meet  some  of  these  difficulties,  Varnier  has  proposed 
to  take  a  skiagram  with  the  patient  in  the  lateral  and  another 
with  her  in  tlie  ventral  posture,  but  he  has  not  overcome  the  technical 
obstacles  in  the  way. 

There  is  yet  another  means  of  diagnosis  of  fcctal  conditions  which 
has  scarcely  at  all  been  employed,  and  which  might  yet  be  made  use 
of.  I  mean  the  detection  of  changes  in  the  chemical  composition  of 
the  maternal  excretions  {vide  p.  418),  and  in  the  microsco])ical 
appearances  of  the  blood.  Progress  in  this  direction  is  in  the  mean- 
time hindered  by  the  fact  that  so  little  is  definitely  known  about 
the  physiological  chemistry  of  pregnancy,  and  still  less  about  its 
pathological  chemistry.  What  a  wide  field  of  research,  and  not 
difficult  research,  there  lies  open  in  connection  with  such  questions 
as  the  occurrence  of  albuminuria,  of  peptonuria,  of  acetonnria,  of 
glycosuria,  of  liiBmoglobinuria,  and  of  urobilinuria  in  pregnancy. 
Some  of  these  changes  in  the  urine  li.ive  been  supposed  to  indicate 
the  occurrence  of  fcctal  death,  but  none  of  them  can  as  j'et  be 
regarded  as  an  infallible  test,  and  in  one  case  at  least— namely,  in 
albuminuria — the  disappearance  of  the  morbid  product,  and  not 
its  appearance,  may  point  to  fcctal  death.  Further,  we  know  little 
of  the  effect  of  illness  (sliort  of  death)  of  the  foetus  upon  the 
maternal  excretions  and  blood.  There  are  many  problems.  Why, 
for  instance,  should  the  ingestion  of  from  60  to  120  grm-s.  of 
glucose  by  the  pregnant  woman  produce  alimentary  glycosuria, 
while  the  non-pregnant  woman  requires  to  take  from  140  to 
ISO  grms.  to  bring  aliout  the  same  eilcct  ?  Why  should  the 
toxicity  of  tlie  maternal  urine  diminish  during  pregnancy  .'  Why 
sliould  I'lunge's  law  (the  ashes  of  the  fu'tus  closely  resemlilc  the 
ashes  of  tiic  milk  of  the  mother  animal)  not  apply  to  tiie  human 
fcEtus  and  mother's  millv?  Whatever  the  answers  to  these 
and   to   other   problems  may   be,   there   can   be   little   doubt    that 


INTRANATAL   DIAGNOSIS  449 

from  tlie  clieiuical  side   will   yet   come  diagnostic  aids  uf  no  small 
importance. 

Intranatal   Diagnosis. 

Even  when  labour  has  commenced,  and  is  in  progress,  it  is  of 
importance  to  diagnose  morbid  states  in  the  foetus  on  its  way  through 
the  maternal  passages.  It  may  be  all-important  to  recognise,  for 
instance,  causes  of  delay  in  labour  due  to  enlargement  of  the  foetal 
body  or  head,  so  that  they  may  be  dealt  with  ere  the  delay  has 
become  a  danger;  it  may  be  well  for  the  peace  of  mind  of  the 
obstetrician  that  the  diagnosis  of  the  presentation  be  made,  and  it 
will  be  an  advantage  for  him  to  be  able  to  forewarn  at  least  the 
relatives  of  the  mother  of  the  arrival  of  a  monstrosity  or  a  dead 
foetus,  for  it  will  at  any  rate  save  him  from  some  of  the  reproach 
associated  with  the  unexpected  appearance  of  such  an  unwelcome 
little  stranger. 

The  symptomatology  of  the  labour  must,  therefore,  be  taken  into 
account,  and  deviations  from  the  iioi-mal  noted,  such  as  excess  of 
liquor  amnii,  or  dryness  of  the  labour,  the  absence  of  firtal  move- 
ments, and  the  like.  Again,  the  most  careful  abdominal  and  vaginal 
examinations  must  be  made.  It  will  now  be  more  easy  to  palpate 
the  fcetus  through  the  abdominal  walls,  for  the  liquor  amnii  will,  in 
part  at  least,  have  drained  away,  and  the  vaginal  palpation  will  be 
facilitated  by  the  opening  up  of  the  os  and  the  exposure  of  the 
presenting  part.  It  may  be  taken  as  a  common  occurrence  for  the 
malformed  part  of  a  monstrous  fcetus  to  present  at  the  os  uteri — for 
example,  the  intestinal  coils  in  exomphalos  and  the  basis  cranii  in 
anencep)haly.  If  the  (actus,  eruditus  fail  to  make  out  the  presenta- 
tion with  ease,  the  erudite  mind  ought  to  think  of  a  monstrosity.  It 
is  a  good  plan  for  the  obstetrician,  when  he  gets  a  chance,  to  palpate 
the  deformed  part  of  a  malformed  foetus,  so  that  he  may  recognise 
it  again  if  he  feels  it  coming  down  the  birth  canal.  The  escape  of 
meconium-stained  liquor  generally,  but  not  always,  forewarns  of 
foetal  death  ;  the  feeling  of  the  hydrocephalic  head  is  characteristic, 
islands  of  bone  in  a  sea  of  membrane ;  and  the  introduction  of  the 
hand  well  into  the  passages  ought  to  detect  the  coming  down  of  a 
distended  fcetal  abdomen  (as  in  ascites),  or  the  presence  in  utero  of 
united  twins.  An  interesting  case  of  hydrocephalus,  with  intestinal 
atresia  diagnosed  during  laliour,  was  put  on  record  by  Salus  (Frag, 
med.  iVehnschr.,  xxi.  529,  1896) ;  it  was  that  of  a  breech  presentation, 
in  which  delay  occurred  after  the  birth  of  the  body  from  the  large 
size  of  the  head ;  whilst  the  trunk  was  thus  protruding  from  the 
maternal  parts,  meconium  of  an  earthy  colour  and  devoid  of  bile  was 
passed  from  the  anus,  and  it  was  concluded  that  there  existed  an 
imperforate  condition  of  the  bowel  in  some  jiart  of  its  extent ;  the 
i  conclusion  was  confirmed  after  birth  by  post-mortem  examination. 
I  Foetal  ichthyosis  may  also  be  recognised  during  labour.  The  presence 
I  of  a  hairy  mole  on  the  shoulder  in,  say,  a  transverse  presentation, 
I  might  prove  misleading  to  a  man  who  thought  that  hair  only  grew 
on  the  foetal  scalp.  There  are  many  other  matters  which  might  be 
29 


450  ANTKNAIAI.    I'A  TI  lOI.OC'i'    AND    inCIF.NK 

referred  to  under  iuUiUialal  diagnosis,  sucli  as  llie  detection  of  fo'tal 
anasarca,  or  of  fcetal  rickets,  from  the  inspection  and  ]iali)ation  of  a 
limb  or  limbs  lying  in  the  vagina,  or  the  feeling  of  tlie  1  tones  of 
the  cranium  of  a  dead  fcrtus;  hut  enough  lias  been  said  to  show 
the  possibilities. 

Postnatal    Diagnosis. 

After  the  morbid  or  dead  fcrtus  is  born,  the  necessity  for  the 
formation  of  a  diagnosis  does  not  disappear ;  for,  if  the  infant  be 
dead,  it  will  be  essential  to  discover  the  cause,  so  as  to  take  measures 
to  prevent  its  recurrence  in  a  future  pregnancy ;  and  if  it  be  dis- 
eased or  malformed,  it  will  be  needful  to  make  a  diagnosis  in  order 
to  institute  the  proper  treatment.  Now,  however,  the  diagnosis  will 
not  differ  in  its  details  from  that  canied  out  by  the  pediatric  or 
general  ijhysician,  and  it  will  liave  lost  much  of  its  difficulty.  The 
disease  or  the  deformity  may  lie  external,  and  need  little  more  than 
recognition ;  on  the  other  hand,  it  may  be  internal,  for  example,  con- 
genital heart  disease  or  pyloric  stenosis  or  diaphragmatic  hernia,  and 
necessitate  the  most  careful  application  of  all  our  diagnostic  methods. 
Finally,  the  placenta  and  membranes  and  cord  ought  always  to  be 
scrutinised,  and,  when  possilile,  submitted  to  microscopical  and 
bacteriological  examination. 

I  may  summarise  this  long  description  of  diagnostic  methods  and 
means  in  a  case-taking  scheme,  which  differs  only  in  some  details 
from  one  published  in  1892  (53). 

I.  Antenatal. 

1.  Clinical  History.  c 

A.  Maternal.  j 

(1)  General  Medical.  ; 

(2)  Reproductive.  f 
n.  Paternal.  | 
C.  Family.  | 

2.  Symptomatology. 

3.  Physical  Examination. 

A.  Maternal. 

(1)  Circulatory,  Respiratory,  and  other  Sj-stems. 

(2)  Reproductive  System. 

B.  Foetal. 

(1)  Alnlominal  Palpation  and  Auscultation. 

(2)  IMensiU'ation  by  Cephalometer,  Callipers,  etc. 

(3)  Skiagrapliy. 

C.  Chemical  and  Microscopical  Examination  of  Excretions  and 

Secretion.'*. 
II.  Intranatal. 
III.  Postnatal. 


t 


CHAPTER    XXVI 

Therapeutics  of  Fn'tal  Diseases  :  Erroneous  0]iinioi)s  ;  Value  of  Fcetal  Life, 
Estimation,  Appreciation  ;  Therapeutic  Fci'ticide  ;  Possibilities  of  Antenatal 
Tlierapeutics  ;  Postnatal  Treatment  of  Antenatal  Morbid  States  ;  Intranatal 
Hygiene  and  Treatment. 

The  goal  of  the  medical  man's  ambition,  and  the  limits  of  his  iisefnl- 
ness  to  his  patient,  are  not  reached  when  the  diagnosis  of  the  malady 
from  which  the  latter  is  suffering  has  been  made.  The  most  exact 
diagnosis  is  unsatisfactory  if  unaccompanied  by  effective  treatment. 
The  end  and  aim  of  all  medical  practice  is  prevention ;  and,  failing 
that,  cin-e ;  and,  failing  that,  amelioration.  A  manual  of  Antenatal 
Pathology  which  contained  no  reference  to  antenatal  hygiene  and 
treatment  might  be  of  great  scientific  value,  but  it  would  lack  practical 
interest.  It  is  the  treatment  of  antenatal  morbid  states,  rather  it  is 
the  hygiene  of  antenatal  life,  that  is  in  the  mind  of  the  inquirer  into 
the  phenomena  of  antenatal  disease  and  death  as  he  prosecutes  his 
research.  He  knows  by  this  time  enough  of  tlie  subject  to  expect 
httle ;  but  he  has  hope,  even  although  it  be  feebly  nourished.  Let 
us  see  whether  his  confidence  is  in  any  degree  justified. 

The  medical  profession  stands  upon  the  threshold  of  antenatal 
therapeutics.  It  has  been  standing  there  so  long  that  even  the  un- 
biassed onlooker  must  have  begun  to  wonder  when  it  intended  to 
enter  in,  whether,  indeed,  it  did  not  mean  to  turn  away  again  from 
the  open  portal.  Not  but  that  there  has  been  some  entering  in,  of  a 
retiring  kind,  unobtrusive,  stealthy,  passing  unobserved  by  the  spec- 
tator who  is  growing  weary  of  watching.  High  time  is  it  that  an 
estimate  be  formed  of  the  probabilities  and  possibilities  of  antenatal 
therapeutics.  Even  if  the  possibilities  turn  out  to  be  small,  vanish- 
ing almost,  it  will  yet  be  better  to  know  than  to  remain  ignorant. 
Omne  ignotum  jjro  magnifico  will  not  serve  as  a  cloak ;  for  the  un- 
biassed onlooker  (already  referred  to)  is  hardly  prepared  to  admit 
the  existence  of  an  omne,  notum  or  ignotum.  It  is,  of  course,  every- 
where admitted  that  much  may  be  done  after  labour,  even  in  labour, 
to  cure  or  at  least  to  ameliorate  morbid  states  arising  during  ante- 
natal life  ;  but  this  is  not  usually  regarded  as  antenatal  therapeutics 
in  the  strict  sense  of  the  term.  It  may  be  claimed,  however,  that  it 
is  an  integral  part  of  the  subject,  and  I  look  upon  the  claim  as  one 
that  must  be  yielded.  In  this  way  the  field  is  greatly  widened ;  and 
the  subject  at  once  becomes  one  of  great  practical  importance.  Even 
in  that  part  which  deals  with  the  treatment  of  the  foetus  still  in 
utero  (and  which  is  regarded  by  many  as  constituting  the  whole  of 
antenatal  therapeutics),  it  wiU  be  found  that  advances  have  been 


452  ANTKNATAI.    1' VIIIOI.OCV    AND    llVdlKNK 

iiuitle  and  victories  won.     Tlie  suljject  is  not  so  liopeless,  although 
neglected,  as  is  generally  su]i]iosed. 

Erroneous  Opinions  on  Antenatal  Therapeutics. 

During  the  last  few  years  I  have  been  honoured  by  inquiries 
from  nieniliers  of  the  profession  as  to  individual  problems  in  ante- 
natal tlierajieutics,  and  l)y  suggestitms  as  to  tiie  extension  of  our 
therapeulir  resources  in  dealing  with  morbid  states  during  fatal  life. 
A  consideration  of  these  suggestions  and  inquiries  has  led  me  to 
believe  that  many  medical  men  hold  erroneous  views  as  to  the 
necessity  of  treating  the  unborn  child,  and  that  some  are  inclined 
to  institute  unfair  comparisons  between  this  and  other  departments 
of  therapeutics. 

In  the  fird  place,  let  me  again  state  that  the  possibility  of 
influencing  morbid  states  that  affect  the  infant  while  in  utero  does 
not  cease  with  its  birth.  Many  malformations  produced  antenatally 
can,  of  course,  be  corrected  postnatally,  and  some  congenital  diseases 
can  be  alleviated,  if  not  cured,  by  therapeutic  measures  instituted 
after  birth.  The  treatment  of  antenatal  morbid  conditions  is  not, 
therefore,  exclusively  antenatal;  it  may  be,  in  part,  postnatal, 
and  its  effects  must  of  necessity  be  largely  postnatal  in  their 
manifestation. 

In  the  second  place,  it  may  be  pointed  out  that  most  physicians, 
if  they  think  about  it  at  all,  compare  the  therapeutics  of  the  diseases 
of  the  foetus  with  the  treatment  of  disorders  of  the  adult,  doubtless 
much  to  tlie  prejudice  of  the  former.  They  contrast  the  many 
medicines  which  can  be  administered  to  the  more  or  less  wilUng 
adult,  with  very  definite  result,  with  the  very  few  drugs  which  can  be 
given,  with  almost  unknown  results,  to  the  foetus  in  utero  (always 
presupposing  that  its  passive  resistance  to  being  drugged  at  all  can 
be  overcome, — that,  in  other  words,  the  placental  barriers  can  be 
passed).  But  in  so  arguing  they  are  not  acting  quite  fairly.  Why 
should  comparison  be  made  between  the  therapeutics  of  the  foetus 
and  that  of  the  adult  ?  We  do  not  contrast  the  tiierapeutics  of  the 
new-born  infant  with  that  of  the  adult,  but  with  that  of  the  infant 
and  child.  Let  us,  therefore,  contrast  antenatal  therapeutics  with 
neonatal  therapeutics.  I  think  I  am  right  in  supposing  that  few 
medical  men  commonly  administer  more  than  two  or  three  drugs  to 
the  new-born  infant ;  that  few  feel  altogether  at  home  in  its  manage- 
ment, medicinal  or  otherwise :  and  that  few  can  boast  of  brilliant 
results  and  assured  triumphs  in  tlie  domain  of  neonatal  therapeutics. 
In  comparing  neonatal  with  antenatal  therapeutics,  we  compare 
similar  things ;  the  one  is  divided  from  the  other,  it  is  true,  by  that 
epoch-making  occurrence,  birth,  yet  thej'  are  in  many  respects 
similar.  A  little  reflection  will  make  it  clear  that,  after  all,  antenatal 
tiiiTapeutics  in  its  scope  and  utility  is  little,  if  at  all,  behind  neonatal 
tlun-apeutics.     Let  us  see. 

Few  drugs  are  needed  by,  or  commonly  administered  to,  the  new- 
born child,  and  even  those  are  of  doubtful  utility :  castor-oil  to  do 


ANTENATAL  AND  NEONATAL  TREATMENT    453 

what  the  colostrum  does  equally  well  or  bettei',  and  dill  water  to 
undo  the  evil  effects  of  unnecessarily  filling  tlie  infant's  stomacli  witli 
sugar  and  water.  The  first  draught  of  the  mother's  milk  thoroughly 
clears  the  bowel  of  meconium.  The  infant  does  not  come  into  the 
world  in  a  state  of  starvation ;  his  tissues  are  not  crying  out  for 
pabulum ;  it  is  doubtful  if,  after  birth,  he  ever  again  receives  so  full, 
complete,  and  well-adaj)ted  a  meal  as  is  provided  for  him  while  still 
in  'utero ;  he  requires  nothing  more  for  eight  hours  after  birtli,  by 
wliich  time  the  mother's  breast  begins  to  supply  his  wants.  Some 
physicians  add  hydrargyrum  cum  creta  to  the  drugs  given  to  the 
new-born,  presumably  on  tlie  principle  that  mercury  for  infants  is 
certaiii  to  do  good,  and  cannot,  at  any  rate,  do  harm ;  but  is  it  not 
somewhat  of  a  reflection  upon  every  one  concerned,  that  it  sliould  be 
deemed  necessary  to  start  every  child  upon  his  postnatal  career  with 
the  specific  for  sj'philis,  always  supposing  that  he  is  free  from  that 
disease?  The  most  rational  plan  of  giving  medicines  to  the  new- 
born infant  is  through  the  mother's  milk  or  by  inunction  through  the 
skin,  wliich  at  this  time  of  life  absorbs  freely ;  but  not  many  new- 
born infants  require  drugs  at  all.  Now,  the  same  general  principles 
apply  to  antenatal  therapeutics.  The  unborn,  like  the  new-born, 
infant  requires  drugs  seldom,  and  he  can  best  receive  them  through 
the  mother,  i.e.,  through  the  placenta,  which,  after  all,  is  in  its  foetal 
part  an  extension  of  the  fa?tal  skin,  or  ectoderm.  In  this  way  arsenic 
and  mercury,  and  doubtless  many  other  remedies,  may  be  admin- 
istered. As  has  been  shown,  there  is  much  ignorance  as  to  the 
conditions  which  favour  or  obstruct  the  passage  of  these  drugs  to  and 
from  the  foetus ;  but  all  is  not  by  any  means  known  regarding  the 
transmission  of  medicines  through  the  milk. 

In  the  third  place,  it  is  an  error  (although  not  so  common  an 
error  as  it  once  was)  to  think  only  of  medicinal  treatment.  There 
are  other  means  of  infiuencing  beneficially  the  maladies  of  all  periods 
of  life.  In  this  respect,  also,  neonatal  and  antenatal  therapeutics 
may  be  compared.  When  an  infant  is  born  into  the  world  in  a  weak, 
puny,  or  delicate  state,  or  when  it  develops  weakness  or  ilhress  soon 
after  birth,  the  best  line  of  treatment  will  often  consist  in  attempting 
to  return  it  to  its  antenatal  surroundings,  in  re-establishing  the 
status  quo  ante  partuni.  In  its  most  complete  development  this 
attempt  finds  expression  and  visible  embodiment  in  the  couveuse,  or 
incubator,  which  has  become  so  important  an  addition  to  the  thera- 
peutic armamentarium  of  the  maternity  liospital.  The  treatment  of 
the  new-born  is  then  environmental  rather  than  medicinal ;  so,  I 
maintain,  should  be  the  treatment  of  the  unborn.  Tlie  foetus,  when 
healthy,  requires  no  external  help,  and,  when  ill,  no  more  than  is 
given  to  the  ailing  new-born  infant  liy  the  pediatric  or  obstetric 
physician.  Indeed,  it  requires  considerably  less,  for  Nature  has 
already  carried  out  a  lai'ge  part  of  the  treatment  by  providing  the 
best  possible  coureusc  ;  for  a  fluid  medium  of  constant  temperature  is 
better  than  an  atmospheric  one,  even  when  artificially  warmed  and 
carefully  sterilised.  When  an  adult  is  ill,  we  order  him  to  keep  his 
bed  in  a  room  of  even  temperature :  when  a  fcetus  is  ill,  we  are  glad 


454  ANTKNATAI.    I'ATl  lOI.OfJV    AM)    HYCUKNE 

to  know  tliat  he  is,  so  to  say,  keciiiu;;'  Iiis  room.  We  are  euibaiiassed 
only  if  lie  leave  it,  for  to  he  prematurely  horn  is  a  serious  matter  for 
a  diseased  fietus;  and  if  this  should  happen,  all  we  can  do  is  to  pro- 
vide another  "  room,"  which  very  imperfectly  resembles  the  uterus, 
namel}',  the  incubator.  But  it  may  bo  asked.  Can  we  in  any  way  aid 
in  keeping  the  iietus  in  utero?  I  thiidv  we  can.  We  can  keej)  down 
the  maternal  temperature  and  prevent  a  sudden  rise,  whicli  would 
loosen  the  intrauUnine  connections ;  we  can  assist  llie  inotlicr's 
excretory  organs  (skin,  kidneys,  intestine)  to  act  vigorously,  and 
throw  olf  the  effete  products  which  pass  in  large  quantity  into  tlie 
maternal  from  the  fietal  economy,  for  maternal  toxamia  wiU  tend  to 
set  up  uterine  action  and  bring  on  labour;  and,  finally,  we  can  do 
something  towards  maintaining  tlie  structural  and  functional  integrity 
of  the  placenta,  for  chlorate  of  potash  would  seem  to  act  as  a 
placental  tonic.  How  it  acts,  whether  on  the  placenta  directly,  or 
indirectly  by  keeping  the  maternal  blood  in  good  condition,  does  not 
so  mucli  matter;  in  my  experience  and  in  that  of  otliers  it  prolongs 
intrauterine  life,  it  maintains  the  placental  functions,  and  so  saves 
the  foetus  from  the  dangers  of  ])reniature  exposure  to  an  extrauterine 
environment. 

In  the  fourth  place,  it  has  been  often  sujiposed  that  the  causes  of 
antenatal  morbid  states  were  special,  peculiar,  and  indeed  unknown 
in  their  nature,  and  that  therefore  the  treatment  must  be  also  (piite 
peculiar  or  perhaps  nil.  Thcrapia  nulla  has  been  too  quickly  written 
as  an  epitaph  over  antenatal  therapeutics.  There  is  good  reason  to 
believe  that  the  same  causes  are  at  work  in  the  antenatal  as  in  the 
postnatal  period  of  life.  The  reader  will  have  learned  from  the  pre- 
ceding pages  that  the  agencies  which,  when  acting  upon  infantile 
and  adult  organisms,  produce  pathogenic  and  toxic  eflects,  are  those 
which  lead  to  pathogenic  and  toxic  effects  when  acting  upon  the 
foetus.  Further,  in  the  part  of  tliis  work  which  is  to  deal  with  the 
morbid  states  of  the  embryo  and  germ,  it  will  be  shown  tliat  ]irt)bably 
these  same  causes  are  again  in  action  in  producing  malformations  and 
monstrosities.  The  results  of  their  action  are  very  various — sterility, 
single  and  double  monstrosities,  abortions,  still-births,  mortinatality, 
twinning,  fcctal  disease,  many  tumours,  congenital  debility,  and 
tendencies  dissolving  heredity  and  leading  to  the  later  development 
of  tubercle,  rheumatism,  gout,  and  many  neuropathic  disorders — these, 
and  not  fcctal  diseases  and  deformities  only,  are  the  protean  jihenomena 
of  Antenatal  I'atiiology.  So  there  is  good  reason  to  believe  that  the 
morbid  causes  also  are  not  one  but  manj',  and  that  all  the  toxic  and 
pathogenic  agents  whose  action  in  postnatal  life  is  known,  may  act 
before  birth  upon  the  developing  organism.  In  this  way  the  poisons, 
such  as  alcohol,  lead,  morphine,  nicotine,  and  the  rest,  and  the 
microbes  and  their  toxins,  such  as  those  of  tubercle  and  the  ex- 
antliemata,  and  to  some  extent  traumatism,  enter  into  the  arena  of 
antenatal  etiology,  and  have  to  lie  taken  into  account  in  the  investi- 
gation of  every  instance  of  Antenatal  I'athology.  So  far  as  has  been 
discovered,  one  and  the  same  morbid  cause  may  produce  in  one 
instance  a  fcetal  disease,  in  another  an  embryonic  monstrosity,  and  in 


VALUE   OF   F(ETAL   LIFE  455 

auotlier  a  tendency  to  the  breaking  of  normal  heredity  in  the  develop- 
ment of  a  proneness  to  certain  maladies  of  body  and  mind  in  later 
life.  Yet  again,  this  same  cause  may  produce  sterility,  emliryonic  or 
fietal  death,  possibly  twinning,  and  certainly  abortion  and  premature 
labour.  In  syphilis  and  tubercle  and  alcoholism  are  to  be  found 
three  morbid  causes  which  may  produce  the  protean  effects  which 
have  been  enmnerated.  Further,  similar  effects  may  be  produced  by 
different  causes,  the  results  depending  apparently  not  so  much  upon 
tlie  nature  of  the  morbid  agent,  as  upon  the  time  of  its  action  and  the 
condition  of  the  organism  acted  upon.  It  is  quite  likely  that  if  it  were 
possible  to  reduce  these  morbid  actions  to  their  ultimate  factor,  it 
would  be  found  to  be  the  common  one  of  interference  with  nutrition, 
and  probably  chemical  in  its  nature. 

If  these  views,  then,  be  correct,  it  follows  that  the  medicines  and 
plans  of  treatment  which  are  appUcable  in  postnatal  life  may,  with 
certain  restrictions,  prove  useful  in  antenatal  life  also.  If  the  pheno- 
mena of  Antenatal  Tathology  are  not  due  to  some  occult  and  myste- 
rious special  cause,  then  their  prevention,  or  even  their  cure,  may 
be  less  hopelessly  looked  for  in  the  tlierapeutic  measures  which  are 
known. 

Having  considered  these  erroneous  ideas  regarding  the  treatment  of 
antenatal  morbid  states,  we  are  now,  I  think,  better  able  to  approacli 
that  great  problem,  and  are  less  likely  to  be  either  disappointed  or 
startled  with  tlie  results.  There  is,  however,  yet  one  other  pre- 
liminary matter  to  be  discussed  before  we  can  take  up  in  detail  the 
possibilities  of  antenatal  therapeutics ;  I  refer  to  the  value  of  fatal 
life. 

The  Value  of  Fcetal  Life. 

Closely  bound  up  with  the  problem  of  the  value  of  fa^tal  life  is 
tlie  question  of  the  amount  of  fretal  death.  What  is  the  antenatal 
death-roll  ?  No  estimate  has  ever  been  formed  of  the  loss  of  life 
which  takes  place  immediately  after  birth  as  the  direct  result  of 
birth,  during  birth  from  the  traumatism  of  labour,  in  the  fu^tal  period, 
in  the  embryonic  epoch,  and  during  germinal  life.  Mortality  tables 
tell  something  of  the  frequency  of  death  during  the  first  months  of 
life,  obstetricians  know  something  of  the  many  times  that  they  have 
to  deal  with  premature  labours,  still-birtlis,  and  abortions ;  but  I  doubt 
whether  the  most  pessimistic  has  an  adequate  conception  of  the  loss 
of  life  in  tlie  earlier  periods  of  antenatal  existence.  Even  if  we 
neglect  all  deaths  occurring  before  tlie  second  month  of  intrauterine 
life,  the  result  is  nevertheless  appaUing.  The  frequency  of  abortions 
lias  been  regarded  by  Tarnier  and  Budin  {Traitd  dc  I'art  des  accoiichc- 
ments,  ii.  47-4,  1886)  as  something  like  one  to  every  three  or  four 
pregnancies ;  since  abortions  are  equivalent  to  frotal  deaths  (in  their 
ultimate  results),  this  means  that  the  fo'tus,  at  the  beginning  of  the 
fcetal  period  of  intrauterine  life,  has  a  25  per  cent,  or  a  20  per  cent, 
risk  of  never  reaching  the  time  of  viability. 

In  maternity  hospital  practice,  ])remature  births  occur  to  the 
extent  of  about  16  per  cent.  (C.  Hahn,  Dcs  ■primaturis,  p.  46,  Paris, 


4r)(i  AXTI'.NAl'AI,    I'ArilOI.OdV    AM)    IIYdll'.NK 

1901),  if  we  re^'aiil  all  the  infants  weighing  less  tiiau  2500  gnus, 
as  prematurely  horn ;  but  it'  iiOOO  grms.  be  taken  as  indicating  pre- 
maturity, then  the  percentage  rises  to  41'r>.  For  practical  purpijses, 
the  frequency  of  premature  labours  in  maternity  iiospitals  may  be 
put  at  20  per  cent. ;  but,  of  course,  this  does  not  enable  us  to 
estimate  the  percentage  in  general  obstetric  practice.  Further, 
premature  birth  does  not  necessarily  mean  fcctal  deatli ;  some  prc- 
luaturely-boru  infants  are  dead  when  born,  and  some  die  very  soon 
afterwards,  but  a  certain  number  survive.  The  number  of  the 
survivors  will  vary  with  the  age  in  fictal  life  arrived  at  when  birth 
took  place,  with  the  means  employed  to  keep  the  infant  alive,  with 
the  season  of  the  year,  etc.  The  variation  will  be  within  wide  limits ; 
it  is  not  difficult  to  find  statistics  of  mortality  among  premature 
infants  showing  any  percentage  between  90  and  10.  It  is  true  that 
recent  reports  show  a  most  gratifying  fall  to  little  more  than  a  G'5  per 
cent,  mortality  (C.  Maygrier,  L'Ohstctrique,  vi.  497, 1901) ;  Init  if  a  wide 
view  be  takeu,  it  is  probaUe  that  50  per  cent,  or  40  per  cent,  must 
still  be  regarded  as  not  uncommon.  I'erhaps,  then,  it  may  be  said 
that  if  a  f(i;tiis  reach  a  viable  age,  and  is  then  born  before  the  full 
term,  he  will  have  a  30  or  40  per  cent,  risk  of  early  postnatal  death. 
Of  course,  it  must  be  added  that  some  fu'tuses  go  to  tlie  full  term, 
and  are  then  born  dead ;  they  are  not  nearly  so  numerous,  but 
statistics  are  difficult  to  obtain,  for  some  of  the  deaths  are  no  doubt 
due  to  obstetric  difficulties,  and  not  to  truly  antenatal  causes.  It 
will  be  seen,  from  what  has  been  stated,  that  it  is  very  difficult  to 
obtain  any  idea  of  the  fatal  death-rate,  for  it  is  almost  impossible  to 
exclude  the  intranatal  deaths  due  to  purely  intranatal  cau.ses,  and  it 
is  far  from  easy  to  estimate  the  mortality  due  to  premature  labours 
and  abortions.  One  conclusion  maj'  perhaps  be  safely  drawn  : 
through  improved  obstetric  methods,  and  the  elaboratiou  of  the  means 
for  keeping  premature  infants  in  life,  and  possibly  also  l)y  the 
amelioration  of  the  condition  of  the  pregnant  woman-worker,  the 
fcEtal  death-rate  is  percejjtibly  less  than  it  was,  say,  fifty  years  ago. 
It  is  very  doubtful,  however,  whether  it  can  be  said  that  this  fall  in 
the  fretal  death-rate  has  done  anything  towards  altering  the  economic 
value  of  foetal  life,  for,  as  will  now  be  shown,  another  and  a  far  more 
important  factor  has  been  at  work  :  I  refer  to  the  fall  in  the  birth-rate. 
From  a  strict  and  rigid  utilitarian  standpoint,  it  may  not  matter 
much  that  there  is  a  high  fictal  death-rate,  so  long  as  there  is  also  a 
high  birth-rate,  so  long  as  the  po])ulation  is  going  up  by  leajis  and 
Ixiunds.  ]5ut  if  not,  what  tlien  ?  Tiie  social  economist  of  the  country 
whose  population  is  stationary  or  receding  will  soon  be  forced  to  take 
an  interest  in  the  f(ctal  death-rate ;  in  liis  mind  the  value  of  fictal 
life  will  undergo  ap])reciation.  He  will,  of  course,  consider  first  the 
cause  or  causes  of  the  diminished  birth-rate;  if  he  find  that  they  are 
removable,  l)e  will  hope  to  see  them  removed  by  legislation  or  some 
other  means;  but  if  he  find  that  they  are  not  removable,  he  will  lie 
forced  back  to  the  plan  of  trying  to  increase  the  nundier  of  living 
full-time  infants  born.  His  idea  of  the  value  of  foetal  life  will  have 
changed.     Now,  there  can  be  no  doubt  that  in  most  civilised  countries 


VALUE   OF   F(];TAI,   LlFl':  457 

there  is  a  drop  iu  the  l)irth-rate,  iieitlier  can  there  be  any  doiiht  tliat 
it  is  due  to  causes  whicli  are  practically  unreniovaWe.  These  causes 
are  chietiy  the  voluntary  prevention  of  concepti(.in  and  the  procuring 
of  early  abortion  in  order  to  pre\'ent  large  families,  and  behind  these 
causes  lies  the  "  wish  for  ease  and  material  enjoyment."  It  is  doubtful 
whether  a  greater  .dissemination  of  educational  opportunities  among 
the  masses  will  lessen  this  tendency ;  at  any  rate,  there  is  reason  to 
fear  that  it  will  be  long  before  it  does  so.  The  fall  in  the  birth-rate 
in  France  has  been  well  known  for  years :  liut  in  the  United  Kingdom 
we  find  a  still  more  startling,  because  more  rapid,  fall  from  a  birth- 
rate of  35  per  1000  in  1875  to  one  of  29  per  1000  in  1900  1  This 
means  in  each  year,  and  with  the  present  population  of  41 J  millions, 
a  deficiency  of  a  quarter  of  a  million  infants.  In  the  face  of  this 
deficiency,  a  slight  improvement  in  the  fcetal  death-rate  is  soon 
counterbalanced.  Tlie  effect,  however,  is  to  increase  the  value  of 
foetal  life,  for  if  the  abortions  and  premature  labours  could  be 
diminished,  and  if  the  diseases  of  fcetal  life  could  be  prevented  or 
cured,  something  at  least  might  be  accomplished  to  check  the  down- 
ward trend  of  the  population.  There  is,  of  course,  no  increase  in  the 
intrinsic  value  of  the  life  before  birth ;  it  is  simply  an  accidental 
appreciation. 

This  appreciation  in  the  value  of  fcetal  life  has  had  an  evident 
effect  in  another  direction;  I  refer  to  the  c|uestion  of  the  relative 
value  of  maternal  and  foetal  life.  This  question  usually  arises  in 
connection  with  the  performance  of  some  obstetric  operation,  such  as 
craniotomy  or  tlie  induction  of  aljortion  or  X'l'emature  laliour,  in 
which  the  life  of  the  foetus  is  sacrificed  or  put  into  jeopardy  on 
behalf  of  the  mother.  Under  the  title  of  "Mother  versus  Child," 
Dr.  S.  Macvie  of  Chirnside  {Tratis.  Edinb.  Ohst.  Soc,  xxiv.  123,  1899) 
dealt  with  this  matter  in  the  form  in  which  he  met  it,  namely, 
inoperable  rectal  cancer  in  a  woman  pregnant  at  the  sixth  month ; 
he  had  to  decide  whether  to  induce  abortion  at  the  sixth  month  or 
premature  labour  at  the  seventh,  or  do  C;T?sarean  section  at  the  full 
time ;  and,  in  attempting  to  decide  the  line  of  procedure,  he  found 
himself  face  to  face  with  the  problem  of  the  relative  value  of  the  life 
of  a  mother  with  inoperable  cancer  of  the  rectum,  and  that  of  an 
unborn  infant  at  the  sixth  month  of  intrauterine  life.  Which  was 
the  more  valuable  life  ?  He  was  still  deliberating  upon  this  matter 
when  circumstances  arose  (increase  in  the  mother's  sufierings,  block- 
ing of  the  rectum,  risks  of  performing  C;esareau  section  in  the 
country)  which  led  him  to  induce  premature  labour ;  the  child  was 
born  alive  and  hved  five  weeks,  and  the  mother  recovered  fi'om  the 
effects  of  the  labour,  and  was  able  for  some  time  to  attend  to  her 
household  duties.  The  problem  in  this  case  was  a  very  involved  one. 
It  usually  arises  in  a  simpler  form  in  the  choice  of  the  alternative 
operations  in  cases  of  contracted  pelvis ;  but  Macvie's  attempt  to 
arrive  at  a  solution  of  the  problem  is  so  ingenious  and  interesting, 
that  it  must  be  considered  more  in  detail. 

If  we  consider  the  question  of  life-expectancy,  it  would  seem  that 
at  twenty  years  of  age  that  of  the  mother  is  barely  equal  to  that  of 


458  AN'ri'-NATAI,    I' A  11  lOI.CXiV    AM)    IIVCllAl-. 

her  new-born  iuranl,  and  al  i-very  subsequent  prcLjnaney  it  is  less. 
Therefore,  if  at  every  birth  after  twenty  years  of  a^e  the  life-ex- 
pectancy is  taken  as  tlie  measure  of  value,  the  new-born  child  is  the 
more  valuable  life.  The  "general  practice,  however,  is  to  regard  the 
mother's  life  as  the  more  valualjle,  although  lier  life-e.\peetancy  may 
be  less  than  that  of  her  child.  "  It  is  not  diilicult,"  writes  I\Iacvie, 
"  to  find  ethical  justification  for  the  practice.  Life-e.xjiectancy  tables 
are  misleading  indices  of  life  values,  unless  the  duration  of  the  ex- 
pectancy covers  the  same  series  of  years.  If  two  lives  have  an 
expectancy  of  twenty  years  eacli,  reaching  from  twenty  to  forty,  they 
may  safely  be  said  to  be  of  equal  value.  Each  individual  would  have 
the  same  time  in  wliich  to  discharge  the  obligations  of  life.  The 
lives  of  mother  and  child  do  not  give  such  synchronous  parallelism, 
and  a  life-expectancy  of  equal  duration  might  give  widely  uneipial  life 
values.  For  example,  if  a  child's  life-expectancy  covered  the  first 
ten  years,  and  the  mother's  reached  from  twenty  to  thirty  years, 
there  would  be  no  hesitation  in  giving  to  the  mother's  tlie  higlier 
value.  The  difficulty  lies  in  determining  the  figure  with  which  to 
multiply  it.  .  .  .  Ethically  regarded,  the  value  of  life  consists  in  the 
discharge  of  subjective  and  altruistic  obligations,  instinctive  or  voli- 
tional, as  the  case  may  be,  and  with  such  opportunity  or  capacity  as 
the  individual  possesses.  To  this  may  be  added  the  due  iierformance 
of  procreative  functions  from  which  the  life  acquires  a  racial  in 
addition  to  an  ethical  value.  In  other  words,  life  ^'alue  is  composed 
of  thi-ee  elements,  personal,  social,  and  racial.  At  certain  periods  of 
life  the  discharge  of  these  obligations  is  an  impossibility,  and  at 
such  periods  life  has  either  not  acquired  or  has  lost  its  highest 
value.  For  example,  the  foetus  in  utero  is  a  parasite  performing  no 
function  whatever."  [This  is  not  quite  correct,  for  there  can  be  no 
doubt  that  its  life  reacts  upon  the  maternal  life  in  an  obscure,  even 
in  a  mysterious  fashion,  either  as  a  stimulus  to  a  high  degree  of 
physiological  activity  or  as  a  cause  of  disease ;  but  the  point  need  not 
be  insisted  upon,  and  Dr.  Macvie's  line  of  argument  need  not  be 
broken.]  "  Its  existence  involves  a  physiological  loss  to  the  maternal 
organism.  Unlike  an  arm  or  a  spleen,  it  performs  no  duty  in  return 
for  its  sustenance.  Its  actual  value  could  only  be  expressed  by  a 
minus  quantity.  Its  potential  value  is  equal  to  its  extrauteriue 
life-expectancy.  If  that  is,  by  reason  of  dangers  ahead,  reduced  to  a 
life-expectancy  muiimum,  its  potential  value  may  never  be  realised. 
The  new-born  child  is  still  parasitic,  tliough  detached ;  and,  though 
it  inhales  its  own  oxygen,  is  still  a  physiological  loss  to  tlie  maternal 
organism.  The  actual  value  is  still  a  minus  quantity,  but  it  lias  begun 
to  realise  its  potentiality  by  satisfying  the  parental  instinct,  and 
contributing  to  the  subjective  element  of  life.  The  mother,  on  the 
other  hand,  has  realised  the  potentialities  of  life.  Value  after  value 
has  been  added  to  lier  existence  as  consciousness,  self-cunsciousness, 
and  volition  developed.  Tlie  later-added  procreative  function  has 
given  it  a  racial  value.  In  the  discharge  of  her  manifold  functions, 
she,  living  less  to  herself  than  any  other  being,  attains  a  higher  self- 
sacrificial  value.     She  is  directly  and  indirectly  contributory  to  the 


VALUE   OF   RKTAL   LIFE  459 

life  of  her  childreu,  and  her  own  life,  to  he  accurately  estimated, 
must  be  multiplied  by  some  fractional  sum  of  theirs.  Thus,  while 
child-life  in  its  partially  developed  stages  must  be  represented  by  a 
varying  fraction,  the  maternal  life  must  be  represented  by  an  integer 
raised  to  an  »"'  power  equivalent  to  her  manifold  functions.  There- 
fore, unless  the  life-e.xpectancy  of  the  child  covers  the  years  in  which 
its  potentiality  is  converted  into  actuality,  the  relative  values  of  the 
maternal  and  foetal  life  will  be  that  of  actual  as  against  potential." 

From  all  this,  and  from  much  more  of  a  like  inconclusive,  per- 
haps even  inconsequent,  kind,  it  may  be  gathered  that  we  cannot 
estimate  the  actual  or  the  I'elative  value  of  fcctal  life.  The  mother's 
^  life  has  a  value  because  she  is  what  she  is ;  the  fcetal  life  has  a  value 
on  account  of  what  it  may  become.  We  are  not  able  for  want  of 
data  to  calculate  life-expectancy  at  either  the  third  or  the  seventh 
month  of  intrauterine  existence,  much  less  at  earlier  dates.  During 
the  last  fifty  years  tliere  has  probably  been  a  slight  increase  in  the 
chances  of  a  fcetus  surviving  till  the  full  term ;  but  against  this  has 
to  be  put  the  fact  that  apparently  parents  ha\'e  decided  that  there 
are  to  be  fewer  fcetuses  to  enjoy  this  enhanced  cliance  of  life.  Pro- 
letaneous  parents  are  to  Ije  rare.  When  the  birth-rate  begins  to  go 
down,  the  value,  economic  as  well  as  sentimental,  of  the  unborn  infant 
begins  to  go  up.     This,  at  least,  is  undoul3ted. 

A  very  practical  question  meanwhile  awaits  an  answer.  Be  the 
value  of  foetal  life  what  it  may  be,  has  any  one  the  power  to  ordain 
that  a  foetus  shall  die  ?  In  whose  hands,  if  in  any  one's,  is  the  jus  vit;e 
iieci  que  ?  Pinard  {An7i.  de  gyndc,  li.  1,  1899 ;  lii.  81,  1899  ;  liii.  1, 
1900),  discusses  this  matter  very  seriously,  and  in  view  of  the  various 
fceticidal  operations  still  in  use  it  requires  serious  discussion.  Pinard 
puts  to  himself  the  following  question  :  "  A  woman  in  labour  cannot 
be  delivered  spontaneously  on  account  of  contraction  of  the  pelvis ; 
the  fretus  is  at  full  term  and  alive,  the  interference  that  you  regard 
as  necessary,  indispensable,  and  indicated,  is  forbidden  to  you  by  the 
patient  herself  or  by  her  relatives;  another  means  of  treatment  is 
proposed  to  you,  and  it  implies  the  death  of  the  infant :  under  these 
circumstances,  what  are  you  to  do  ? "  Pinard  examines  in  turn  the 
paternal  right  to  decree  the  death  of  the  offspring,  the  maternal 
right  to  demand  the  same  thing,  the  power  that  the  medical  attend- 
ant has  during  a  confinement  to  decide  whether  the  infant  shall  live 
or  die,  and  the  right  of  any  one  else  (e.g.  the  managers  of  a  mater- 
nity hospital)  to  interfere  in  the  matter.  The  conclusion  would 
seem  legitimately  to  be  that  the  right  of  life  or  death  over  the  infant 
belongs  to  no  one,  neither  to  the  father  nor  to  the  mother,  nor  to 
the  medical  attendant,  nor  even  to  the  directors  of  the  hospital. 
The  infant's  right  to  his  life  is  an  imprescriptible  and  sacred  right 
which  no  power  can  take  from  him.  The  right  of  choosing  the 
operation  to  be  employed  belongs  to  the  medical  attendant,  and  his 
duty  is  to  both  his  patients,  to  child  as  well  as  to  mother.  If  it 
seem  to  be  advantageous  for  the  mother,  embryotomy  or  embryulcia 
may  be  i)erformed  upon  the  dead  fcetus  ;  but  if  the  unborn  infant  be 
still  alive,  the  logical  and  the  moral  conclusion  is  that  its  birth  be 


460  ANTKNAI'AI,    1>AI'I  lOI.OCI^     AND    IIVCII'.NK 

ellected  witliout  delibeiately  killing  it.  "  Sacrifier  I'enfant  pour 
sauver  la  mere  est  une  k'geiiile  qui  doit  disparaitre "  (C.  Zalackas, 
Proijrrs  mi'd.,  3  k.,  xiii.  421,  1901).  JJut  if  tiu!  mother  forbid  tlie 
special  operation  needed,  what  then  !  Tlie  obstetrician  is  hardly 
ready  with  an  answer  yet.  Fortunately  many  thinifs  are  contri- 
buting to  make  the  abolition  of  craniotomy  upon  the  living  fo?tus 
possil)le :  the  great  fall  in  the  mortality  from  Ca-sarean  section  at 
the  full  time,  the  introduction  of  symphysiotomy,  the  improvement  of 
the  forceps,  the  development  of  the  means  for  keeping  in  life  the  pre- 
maturely born  infant;  these  and  other  advances  in  the  obstetric  art 
are  having  a  manifest  influence  upon  professional  opinion  in  this 
matter.  As  to  therapeutic  fu'ticide,  or  the  induction  of  labour  before 
the  foetus  has  arrived  at  a  viable  age,  it  is  possible  for  some  doubt  to 
arise,  when  it  seems  certain  that  the  mother  if  undelivered  will  die, 
and  if  delivered  will  live.  The  thinking  obstetrician  awaits  with 
impatience  the  discovery  of  some  alternative  means  of  dealing  with 
such  conditions.  Let  him,  as  he  thinks,  repeat  to  himself  tlie  legal 
maxim,  "  (^)ui  in  utero  est,  pro  jam  nato  habetur,"  and  extend  its 
application  to  matters  other  than  tlie  succession  to  estates.  Surely 
it  will  yet  be  found  possible  to  deal  with  hyperemesis  in  pregnancy 
in  some  other  way  than  by  terminating  pregnancy  before  the  se\'enth 
month,  and  so  sacrificing  the  product  of  conception. 

Possibilities  of  Antenatal  Therapeutics. 

In  many  respects  the  field  of  research  which  has  been  designated 
Antenatal  Pathology  resemljles  a  battlefield,  rather  perhaps  a  whole 
campaign.  It  is  indeed  a  field  thickly  strewn  with  the  dead,  the 
dying,  the  wounded,  the  maimed ;  for  it  is  not  only  antenatal  death 
that  has  to  be  taken  into  account,  we  have  to  think  of  the  aute- 
natally  wounded,  crippled,  and  diseased.  Now,  in  such  a  campaign, 
it  will  be  evident  that  the  individual  may  require  medical  treatment 
after  the  battle,  during  the  campaign,  or  before  the  wai'.  For  the 
wounded  from  the  battle  the  Army  Medical  Department  provides 
the  ambulance  corps,  the  field  hospital,  and  the  base  hospital :  but  it 
does  more,  it  endeavours  to  keep  the  troops  healthy  and  in  a  healthy 
environment  during  the  campaign,  and  by  means  of  a  good  water 
supply  and  suitable  food  sends  them  into  the  fight  fit  to  bear  the 
strain  to  which  they  wiU  assuredlj'  be  suljjected.  Yet  more,  liefore 
the  campaign  is  begun,  the  medical  inspection  of  recruits  is  the 
subject  of  great  care,  and  only  such  are  selected  as  give  promise 
of  strong  and  healthy  development ;  and,  when  selected,  these  are 
still  further  trained  until  they  become  almost  perfect  fighting 
machines.  Like  all  comparisons,  this  one  may  be  pushed  too  far; 
but  it  may  be  said  generally  that  the  postnatal  treatment  of  morbid 
states  arising  during  birth,  or  before  birth,  corresponds  to  the  field 
and  base  hospitals,  being  mainly  reparative  and  palliative ;  that 
intranatal  therapeutics  and  tlie  treatment  of  the  fo'tus  and  embryo 
may  be  likened  to  the  care  of  the  soldier  during  the  battle  and  in 
the  whole  campaign,  being   mainly  preventive ;   and  that  germinal 


POSTNATAL  TREATMENT  4G1 

therapeutics  resembles  iu  its  possibilities  the  work  of  the  recruiting 
sergeant  and  the  drill  instructor,  being  mainly  selective  and  prepar- 
atory. The  watchwords,  then,  in  both  cases,  must  be  repair,  i)reveut, 
prepare,  and  select  with  care.  Here  we  have  chiefly  to  do  with  the 
treatment  of  foetal  maladies  during  the  foetal  period,  but  some  re- 
ference must  also  be  made  to  treatment  during  the  later  and  earlier 
periods. 

Postnatal  Treatment  of  Antenatal  Morbid  States. 

It  may  Ije  thought  to  be  almost  a  work  of  supererogation  to  enter 
into  details  regarding  what  may  be  done,  after  the  birth  of  the  infant, 
to  remedy  the  ills  with  which  it  comes  burdened  into  its  extrauterine 
existence,  but  it  is  doubtful  whether  the  medical  profession  realises 
how  much  may  be  done,  and  is  done,  in  this  direction.  Few  indeed 
are  the  malformations  \\-hicb  are  comiiatible  with  the  life  of  the 
individual  that  have  not  now  come  under  the  sway  of  the  surgeon, 
and  there  are  several  instances  in  which  his  skill  has  made  anomalies 
that  were  formeily  regarded  as  certainly  lethal  no  longer  so.  Now, 
the  malformations  and  monstrosities  are  not,  strictly  speaking,  foetal 
in  origin,  but  the  opportunity  of  treating  them  comes  at  the  same 
time,  namely,  at  birth ;  they  are,  therefore,  referred  to  here,  although 
their  fuller  consideration  will  be  found  in  the  part  of  the  work  which 
deals  with  Teratology.  Less  immediate  and  striking  beneficial  results 
have  followed  the  ministrations  of  the  physician  and  obstetrician; 
but  hei'c  also  noteworthy  advances  have  to  be  reported. 

As  has  been  said,  it  is  in  the  domain  of  surgery  that  the  postnatal 
treatment  of  antenatal  morbid  states  has  secured  its  most  noteworthy 
triumphs.      Club-foot,    cleft    palate,   hare-lip,  phimosis,   imperforate 
hymen  and  anus,  congenital  dislocation  of  iiip,  shoulder,  and  knee, 
torticollis,   spina    bifida,    congenital  fistulte,   cysts    and    tumours    of 
various   regions,   umliilical   and   other   hernia?,   extroversion   of  the 
bladder,  atresia  of  urethra,  vulva,  or  vagina,  epispadias,  hypospadias, 
non-descent  of  the  testicle,  vulvar  anus,  supernumerary  digits,  syn- 
dactyly, congenital  absence  of  tibia,  filjula,  and  radius,  and  many 
other  conditions  quite  as   markedly  antenatal  in   origin,  are  every 
day  taxing  the  ingenuity  of  the  surgeon.     In  the  repair  of  some  of 
these  deformities  surgery  has  been  quite  successful ;  in  others,  such  as 
ectopia  vesica.',  congenital  dislocations,  and  absence  of  fibula  or  radius, 
only  a  moderate  degree  of  success  has  been  registered.     E^■en  in  the 
latter,  however,  there  has  been  progress ;  attempts  to  close  the  bladder 
in  extroversion  of  that  organ  have  been  abandoned  for  the  implanta- 
j  tion  of  the  ureters  into  the  rectum,  and  that  in  its  turn  seems  likely 
I   to  give  way  Ijefore  the  implantation  of  them  into  the  dorsum  penis  ; 
the  so-called  bloodless  methods  of  reducing  congenital  dislocation  of 
'   the  hip  appear  to  be  gaining  ground,  as  compared  with  the  various 
I  cutting  operations,  and  so  also  with  other  deformities  and  their  treat- 
I  ment.     Further,  it  cannot  be  doubted  that  new  triumphs  await  the 
j  orthopaedic  surgeon  in  the  dealing  with  such  conditions  as  meningo- 
I  cele,  encephalocele,  parasitic  or  attached  fcfituses  and  united  twins 


462  ANTF.NATAT,   1'ATI1()I.(X;Y    AND    IIVCIF.NF. 

(Chapot-PrL-vost,  Chirurgie  den  Tt'ratopoffcs,  Paris,  1901).  Scarcely 
any  serious  attempts  have  yet  been  made  to  correct  tiie  internal 
malformations  :  and  the  reparative  surgery  of  congenital  diapliragmatic 
hernia,  of  kidney  in  the  pelvis,  of  intestinal  and  resopliageal  atresia, 
and  tlie  like,  has  to  l)e  elaborated. 

The  results  obtained  by  the  pliysician  in  his  treatment  of  ante- 
natal morbid  states,  although  less  brilliant  than  tliose  of  the  surgeon, 
have  been  sufficiently  good  to  encourage  further  ellbrts.  It  is  un- 
necessary to  do  more  than  refer  to  the  beneficial  effects  of  medicinal 
treatment  of  the  manifestations  of  congenital  syphilis ;  and  the  value 
of  thyroid  feeding  in  cretinism  and  infantilism  is  well  known.  It 
must,  however,  be  confessed  that  little  success  has  as  yet  attended 
the  medical  treatment  of  the  congenital  skin  diseases ;  and  ichthyosis, 
tylosis,  sclerema,  hypertrichosis,  hypotrichosis,  na-vus  neuroticus,  and 
congenital  elephantiasis  must  still  be  looked  upon  as  nearly  intract- 
able. The  ordinary  form  of  jaundice  of  the  new-ljorn  yields  readily  to 
treatment  of  the  simplest  kind,  but  the  grave  ftirm  does  not  yield  at 
all.  Umbilical  htenrorrhage  usually  requires  surgical  interfeience, 
and  that  of  a  very  active  kind,  to  control  it ;  congenital  heart  disease 
handicaps  the  individual  for  life,  and  congenital  dropsical  states  are 
rarely  amenable  to  the  drugs  of  the  physician.  There  are,  however, 
hopeful  signs  in  connection  with  congenital  hyi)ertrophy  of  the 
pylorus,  fcctal  endocarditis,  foetal  goitre,  etc. 

On  the  other  hand,  wonderful  results  have  been  obtained  in  the 
branch  of  medical  practice  that  deals  with  congenital  defects  and 
diseases  of  the  nervous  system.  Witness  the  effect  of  medically 
regulated  educational  training  upon  the  congenitally  blind,  or  deaf 
and  dumb,  or  idiotic.  The  combination  of  medical  supervision  with 
educative  methods  has  almost  made  the  blind  to  see,  the  deaf  to  hear, 
the  dumb  to  speak,  and  the  idiot  to  understand.  This  is  no  random 
statement,  for  every  one  knows  what  the  congenitally  lilind,  deaf,  or 
dumb  can  accomplish,  notwithstanding  his  infirmity.  With  regard 
to  idiocy,  the  following  sentence  contains  a  report  of  the  results  of 
twenty  years'  work  in  its  alleviation  (Shuttleworth  in  Hack  Tuke's 
Dkt.  Fsycholog.  Med.,  ii.  675, 1892).  "  Of  patients  discliarged  after  full 
treatment,  10  per  cent,  are  self-supporting,  whilst  another  10  per  cent, 
would  he  so  if  they  had  obtained  suitable  situations,  and  about  20 
per  cent,  were  reported  as  useful  to  their  friends  at  home." 

In  one  direction,  however,  the  treatment  of  idiocy  has  not  been 
altogether  encouraging.  I  refer  to  craniectomy  for  the  microcephalic 
form  of  it.  The  operation  is  not  uncommonly  followed  by  evident 
and  immediate  improvement,  which  continues  up  to  a  certain  point, 
and  then  all  that  has  been  gained  is  too  often  steadily  lost.  The 
reason  probably  is  that  in  primitive  microcephaly  the  arrest  in  brain 
development  has  occurred  before  the  fourth  month  of  intrauterine 
life,  and  that,  therefore,  the  division  of  the  cranial  vault  does  not 
reach  the  root  of  the  mischief;  it  is  not  the  cranium  liut  the  lirain 
that  is  at  fault.  In  cases  developed  later,  the  o]ieration  is  theoret- 
ically more  hopeful.  In  this  relation  it  may  not  be  out  of  place 
to   refer   to   the  treatment  of  cranial  depressions  in  the  new-born 


INTRANATAL  TREATMENT  iG?, 

by  trephining.  Sometimes  the  natural  resiliency  of  the  bones  alone, 
or  aided  by  manipulation  (Munro  Kerr,  Tram^.  Edinh.  Ohst.  Soc, 
xxvi.  42,  1901),  restores  the  normal  form  of  the  head,  and  obviates 
symptoms ;  but  this  good  result  does  not  always  follow.  In  a  case, 
of  which  Dr.  D.  1).  Jennings  {Trans.  Edinh.  Ohst.  Soc,  xix.  105, 
1894)  kindly  sent  me  the  notes,  the  use  of  forceps  had  produced  a 
distinct  depression  of  the  left  frontal  bone ;  pneumatic  suction  was 
first  tried,  and  that  failing,  tlie  trephine  was  employed  and  the  bone 
elevated ;  the  child  made  an  uneventful  recovery.  It  seems  to  me 
that  this  mode  of  treating  congenital  depressions  and  fractures  of  the 
cranium  might  l)e  extended  with  advantage. 

Part  of  tlie  postnatal  treatment  of  antenatal  morbid  states  falls 
into  the  hands  of  the  obstetrician.  He  it  is  who  has  to  deal  witli 
apnoea  neonatorum ;  and  it  will  be  well  if  he  give  heed  to  the  causes 
of  this  morbid  state,  for  it  is  very  certain  that  all  instances  of  still- 
birth are  not  due  to  one  cause,  and  are  not,  therefore,  all  amenable  to 
the  same  treatment.  The  obstetrician  ought  to  scrutinise  each  case, 
endeavour  to  ascertain  the  special  cause,  and  treat  accordingly.  It 
also  falls  within  the  province  of  obstetrics  to  examine  the  new-born 
for  fractures,  dislocations,  and  imperforations,  and  to  remedy  them  as 
far  as  may  be.  I  need  not  refer  to  the  incubator  and  the  wet-nurse 
in  the  rearing  of  premature  infants ;  l:)ut  it  may  be  necessary  to 
supply  to  the  milk  certain  minei'als  {e.rj.  iron)  which  the  foetus  gets 
through  the  placenta  in  the  last  two  months  of  intrauterine  life. 

Intranatal  Hygiene  and  Treatment. 

Intranatal  treatment,  under  which  I  include  the  management  of 
the  infant  during  labour,  both  in  the  uterus  and  in  the  vagina,  is 
entirely  in  the  hands  of  the  obstetrician.  It  is  mainly  preventive  in 
character.  In  discussing  the  intranatal  factor  in  neonatal  pathology 
(vide  pp.  44-56),  I  pointed  out  some  of  the  risks  run  by  the  infant  on 
his  way  through  the  birth  canals.  There  is,  for  instance,  the  danger 
of  septic  or  gonorrhoeal  or  syphilitic  infection  affecting  the  eyes  or 
mouth  or  lungs ;  this  danger  may  be  almost  entirely  averted  by  the 
prophylactic  vaginal  douche  during  labour,  and  by  the  cleansing  of 
not  only  the  eyes,  but  also  the  nose  and  mouth  of  the  child  immedi- 
ately after  birth.  Prophylactic  douching  in  labour  for  the  sake  of 
the  infant  is  a  procedure  the  full  value  of  which  has  not,  I  think, 
been  fully  appreciated  as  yet.  The  introduction  of  air  into  the  uterus 
in  some  cases  of  labour  (breech  presentations,  prolapse  of  cord)  to 
obviate  asphyxia  has  been  reconnnended,  but  it  is  of  doubtful  value 
(iiapin,  Ann.  dc  gynic,  lii.  326,  1899).  Again,  the  obstetrician  has  it 
in  his  power  to  prevent  tetanus  neonatorum  by  the  application  of 
surgical  cleanliness  to  the  dressing  of  the  umbilical  cord,  and  by  the 
same  means  it  may  be  confidently  anticipated  that  erysipelas  neo- 
natorum and  omphalitis  with  defective  closure  of  the  umbilical  ring 
will  be  banished  from  practice.  Porak  (Ann.  de  [lynec,  lii.  122, 1899) 
has  proposed  crushing  of  the  umbilical  cord  (omphalotripsy)  with  a 
special  kind  of  forceps  (omphalotribe)  instead  of  the  ordinary  ligature 


464  AN  ri-.NATAI.    I'ATI  lOI.OC^     AM)    I  nciKNK 

ami  section ;  and  il  luiist  be  admitted  tliat  the  present  mode  of 
allowing  the  gelatinous  stump  of  the  cord  to  separate  by  mummifica- 
tion does  not  seem  to  fulfil  the  requirements  of  ase])tic  surgery.  The 
rational  treatment  fif  the  physiological  l!(j\v  f)f  milk  from  the  breasts 
of  the  new-born  will  prevent  many  of  the  cases  of  mannnary  abscess 
due  to  the  nustaken  notion  in  midwives'  minds  of  the  necessity  of 
"  breaking  the  breast  strings."  The  almost  complete  banishment  of 
ergot  until  after  the  infant  is  born,  has  already,  doubtless,  saveii  many 
infantile  lives  ;  and  the  rapid  delivery  of  the  second  twin  is,  I  believe, 
a  step  in  the  right  direction. 

Further,  every  improvement  in  obstetrical  instruments  and 
manipulations  is  beneficial  to  the  foetus.  The  better  the  forceps, 
and  the  more  correctly  it  is  applied  in  the  right  cases,  the  greater 
will  be  the  infant's  chance  of  being  born  alive  and  free  from  intra- 
cranial ha?morrhages  and  facial  paralysis ;  and  the  more  thorough 
the  obstetrician's  knowledge  of  the  safe  methods  of  delivery  in 
contracted  brims,  in  face  cases,  and  in  head-last  labours,  the  better 
it  will  be  for  the  child.  It  may  be  suggestetl,  further,  tiiat  in  cases  of 
fluid  accumulations  in  tlie  foetus,  such  as  hydrocephalus,  ascites,  and 
distended  bladder,  diagnosed  in  labour,  it  may  be  well  to  aspirate 
instead  of  widely  incising  the  affected  region  of  the  infant ;  the 
tapping  of  the  spinal  canal  in  breech  cases  with  hydrocephalus  ought 
to  be  kept  in  mind.  Ji 

It  will  not  be  out  of  place  if  I  here  strongly  insist  upon  the  ' 
necessity  for  the  registi'ation  of  still-births  that  exists  in  our  country. 
Registration,  if  it  were  obligatory,  would  necessitate  necropsy,  and 
necropsy  would  do  much  to  familiarise  the  medical  practitioner  with 
the  appearances  of  still-born  infants,  and  would  be  of  enormous  value 
in  elucidating  the  causes  of  intrauterine  and  intranatal  death.  Tidy 
{Legal  Medicine,  ii.  253,  1883),  says : 

So  notorious  is  it  that  a  large  number  of  these  ileatli.s  couM  be 
averted,  that  some  legislation  is  urgently  needed,  requiring  that  still-borns, 
whose  bodies  weigh,  say,  not  less  than  2  lbs.  (the  average  weight  about 
tlie  sixth  and  seventh  months,  and  at  which  age  children  are  viable), 
should  not  be  buried  without  registration  and  a  medical  examination. 

Although  it  may  not  be  well  to  insist  upon  it  by  law,  it  would 
also  be  most  beneficial  to  our  treatment  of  antenatal  states  if  fa?tuses 
of  less  than  six  months  were  also  submitted  to  post-mortem  investi- 
gation liy  the  medical  man  in  whose  practice  they  occurred. 


■•''  THE 


CHAPTER    XXVII 

Hygiene  and  Therapeutics  of  Ftetal  Life  :  the  Hospitalisation  of  the  Pregnant ; 
"Plea  for  a  Pre-Maternity  Hospital"  ;  "Sanatoria  de  grossesse  "  ;  Hygiene 
of  Pregnancy;  Diet,  Occupation,  Exercise,  Dress,  etc.  ;  ^Irdiialion  of  the 
FiL'tus,  in  Syphilis,  Placental  Disease,  Nervous  JMal^idics,  I  l;riiiophilia  ; 
Transmission  of  Immunity;  Genuinal  Therapeutics;  ( 'innlusidu. 

Antenatal  Hygiene  and  Treatment. 

Hitherto  I  have  referred  simply  to  the  treatment  which  may  he 
adopted  after  or  during  liirth  to  correct  or  ameliorate  the  morhid 
changes  which  are  produced  before  birth.  I  have  not  gone  into 
details,  for  the  measures  I  have  alluded  to  are  all  well  known  or 
can  be  learned  from  text  -  books  of  Medicine,  Surgery,  and  Mid- 
wifery. I  have  now,  however,  to  describe  antenatal  hygiene  and 
treatment  in  the  true  and  strict  sense  of  the  word,  1  mean  the 
antenatal  prevention,  cure,  or  amelioration  of  morbid  states  arising 
in  antenatal  life.  This  is  a  subject  which  is  not  found  discussed  in 
the  ordinary  text  -  books.  I  have  already  pointed  out  some  of  the 
erroneous  opinions  that  are  held  about  it,  and  can  therefore  proceed 
at  once  to  set  forth  what,  to  my  mind  at  least,  can  be  securely  affirmed 
concerning  it. 

It  is  possible  to  bring  hygienic  and  medicinal  influences  to  bear 
upon  the  fcetus  while  still  in  utero,  but  it  is  absolutely  necessary  that 
these  shall  act  first  upon  the  mother ;  antenatal  treatment  is  prim- 
arily maternal ;  it  cannot  be  otherwise.  The  foetus  is  immediately 
surrounded  by  the  liquor  amnii — its  hydrosphere  ;  around  that  again 
are  the  maternal  tissues  and  placenta  which  together  constitute  the 
foetal  biosphere.  For  any  infiueuce  to  act  upon  the  foetus,  it  must 
influence  it  through  its  environment,  through  its  hydrosphere  and 
its  biosphere.  One  can  produce  an  effect  upon  the  unborn  infant  by 
altering  the  condition  of  its  environment  or  by  transmitting  medicinal 
suljstances  to  it  throvigh  its  environment.  Of  these  two  methods  the 
former  is  probably  the  more  important ;  theoretically,  it  is  possible 
to  separate  them,  but  it  is  doubtful  whether  in  practice  this  can  be 
done.  The  first  step,  therefore,  in  the  direction  of  successful  treat- 
ment of  the  unborn  infant  must  be  successful  treatment  of  the 
pregnant  mother.  Here,  on  the  very  threshold  of  the  subject,  we 
meet  with  a  check  ;  for,  when  we  come  to  consider  it,  we  realise 
that  about  the  physiology  of  pregnancy,  and  more  especially  about 
its  pathology,  our  knowledge  is  very  imperfect.  Further,  if  we  set 
about  to  try  to  remedy  this  defect  in  our  knowledge,  we  discover  that 
there  is  no  hospital  wliere  we  can  study  the  normal  and  pathological 
3° 


466  ANTKNATAl.    I' A  TllOI-OdV    AND    I  lYdlF.NK 

plienomeua  of  pregnancy  as  we  can  those  of  laliour  or  of  the  puer- 
periuni  or  of  the  non-pregnant  state.  It  was  this  reason  among  others 
that  lead  me  to  puliHsli  in  tlic  L'rilisk  ^f(■(li(■al  Jmiriud  of  April  G, 
1901,  a  "  riea  for  a  rro-Maternity  Hospital."  As  the  plea  ])uts 
forth  my  views  on  this  matter  in  a  concise  fashion,  I  reproduce  it 
liere,  simply  altering  the  word  "  pro-maternity  "  into  "  pre-materuity," 
as  jjeing  the  more  correct  form. 

A  Plea  for  a  Pre-Maternity  Hospital  or  Home. 

In  youlli  or  early  iiiaiilnxHl  oiu'  plans  enter] irisi'.s  and  huiiefully  endjurks 
upon  projects  which  in  old  age  are  put  aside  as  visionary  or  Utopian ;  no 
one  blames  Youth  for  so  planning  and  ijvojecting,  not  even  Age.  La 
jeunesse  vit  d'espi'rance,  la  rieiUesse  de  souvenir.  "  Youth  lives  on  hojie,  and 
old  age  on  remembrance  "  ;  and  a  reversal  of  the  role>!  woidd  be  unfitting, 
grotesque  even.  So  in  the  infancy  of  the  twentieth  century  it  is  per- 
missible to  suggest  schemes  which  in  the  old  age  of  the  nineteenth  might 
have  been  characterised  as  vain  or  stigmatised  as  chimerical.  The  young 
century  is  full  of  hope,  and  is  not  ashamed ;  la  jetinegse  vif  d'espi'rance. 
The  cure  of  cancer ;  the  prevention  of  the  preventible  (hut  not  yet  pre-  ' 
vented)  diseases  ;  the  laying  of  the  spectre  of  morbid  heredity ;  the 
"  suppression  of  the  weeds  to  give  the  flowers  a  chance  "  :  these  are  some 
of  the  hopes  in  the  beating  heart  of  the  twentieth  century,  and  the  faint 
echoes  of  "  fantastic,"  "  imaginary,"  "  impossible  "  from  the  nineteenth  do 
not  cause  it  to  beat  less  high.  As  the  years  roll  on,  it  may  be  necessary 
to  confess  to  partial  failure  ;  it  will  assuredly  be  necessary  to  revise  the 
plans  of  procedure — it  will  probably  be  found,  for  instance,  to  be  better 
to  try  to  turn  the  weeds  into  flowers  rather  than  to  suppress  them ;  but 
who  shall  dare,  in  full  remembrance  of  what  has  been  accomplished  in  the 
past  century,  to  set  linuts  to  the  progress  to  be  achieved  in  the  present? 

In  the  sphere  of  medicine,  one  of  the  most  noteworthy  and  praiseworthy 
advances  of  the  nineteenth  century  was  the  birth  and  coming  of  age  of 
scientific  gynecology;  it  is  difficult  to  realise  that  in  1801  ovariotomy  was 
unknown,  and  special  hospitals  for  the  treatment  of  gynecological  diseases 
xmdreamed  of,  and  yet  these  are  solid  facts.  The  advances  in  the  sister 
svdsject  of  obstetrics  were  also  numerous  if  not  so  startling  :  there  were  im- 
provements in  the  construction  of  instruments  and  in  the  mode  of  their  use, 
there  was  the  discovery  of  the  real  nature  of  puerperal  fever  and  of  means 
for  preventing  it,  and  there  was  the  growth  of  correct  views  as  to  the 
management  and  internal  arrangements  of  the  maternity  hospital  conse- 
quent upon  the  recognition  of  the  value  of  antisepsis  and  asejisis.  But 
there  was  one  department  of  obstetrics  in  which  the  same  degree  of  progress 
could  hardly  be  reported, — that,  namely,  of  the  pathology  of  pregnancy. 
At  the  end  of  the  jiast  century  obstetricians  were  still  in  doubt  as  to  the  ■ 
real  nature  of  eclampsia  gravidarum,  of  hyperemesis  gravidarum,  of  the 
malignant  jaundice  of  pregnancy,  of  hydramnios,  of  hydatid  mole,  and  of 
most  of  the  idiopathic  diseases  of  the  fcetus  and  of  many  of  the  causes  of 
foetal  death  ;  at  the  best,  they  were  but  slowly  seeking  after  the  truth,  being 
much  hampered  by  the  absence  of  reliable  information  concerning  the 
physiology  of  pregnancy,  and  more  especially  the  physiological  chemistry 
of  pregnancy.  The  condition  of  the  urine  of  the  pregnant  woman,  its 
toxicity,  the  changes  in  her  blood,  the  modifications  in  her  nervous  system, 
the  state  of  her  thyroid  gland,  the  cause  of  the  phj'siological  vomiting  of 


U 


PRE-MATERNITY    HOSPITAL  467 

prei^'nancy,  tlie  origin  of  the  liqtior  amiiii,  tlie  unture  of  the  iilacciital  inter- 
changes, the  physiology  of  the  fcetus,  the  inter-relation  of  the  life  of  the 
mother  and  the  foetus, — these  and  many  other  matters  were  imperfectly 
known  or  merely  guessed  at  in  the  nineteenth  century.  Was  it  strange  or 
inexplicable  that  eclampsia  and  liyperemesis  continued  to  claim  their  many 
victims— mothers  and  foetuses — and  that  most  obstetricians  were  in  almost 
complete  ignorance  as  to  the  state  of  matters  in  the  gravid  uterus,  and 
found  it  safest  to  make  their  diagnosis  of  the  health  or  disease  or  deformity 
of  the  uterine  contents  after  their  expulsion  ?  Of  course,  the  foetal  heart 
was  listened  to,  and  a  few  conclusions  drawn  therefrom,  and  there  was 
a  certain  degree  of  accuracy  attained  in  the  palpation  of  foetal  parts  ; 
but  antenatal  diagnosis  was  far  from  exact,  and  it  was,  indeed,  little 
attempted. 

The  question  may  now  be  fairly  asked,  if  we,  in  the  twentieth  century, 
are  going  to  be  contented  with  the  knowledge  (or  ignorance)  of  the  nine- 
teenth in  these  matters  of  the  physiology  and  pathology  of  pregnancy,  with 
the  maintenance  of  the  status  quo  ante  ?  I  suppose  obstetricians  everywhere 
will  agree  that  no  such  easy  contentment  is  possible  or  to  be  thought  of, 
with  the  maternal  mortality  from  eclampsia  what  it  is,  and  with  the 
number  of  abortions  and  antenatal  deaths  and  malformations  what  it  is. 
This  being  so,  the  next  question  is,  whether,  with  the  methods  and  material 
at  our  disposal,  we  are  making  all  the  progress  that  is  possible,  and  whether 
any  further  means  can  be  suggested  for  the  perfection  of  antenatal  diagnosis 
and  its  certain  concomitant,  the  improvement  of  antenatal  therapeutics  1  I 
think  it  must  lie  admitted  that  we  are  not  making  all  possible  haste  towards 
the  solution  of  the  many  problems  of  prenatal  diagnosis  and  treatment,  and 
I  think  that  there  is  a  means  of  investigation  which  has  not  yet  been  tried, 
at  least  not  yet  attempted,  on  a  large  scale  and  in  a  systematised  fashion. 
Herein  lies  the  plea  for  the  pre-maternity  hospital. 

The  pre-maternity  hospital  need  not  be  a  separate  establishment ;  it 
may  quite  well  be  an  annexe  of  the  maternity ;  in  time  it  may  come  to  be 
of  equal  size  with  the  maternity,  but  it  must  be  distinct  from  the  maternity  ; 
it  will  be  for  the  reception  of  women  who  are  pregnant,  but  who  are  not 
yet  in  labour.  In  the  first  place,  doubtless,  it  will  be  for  the  reception  of 
patients  who  have  in  past  pregnancies  suffered  from  one  or  other  of  the 
many  complications  of  gestation,  or  in  whose  present  condition  some 
anomaly  of  the  pregnant  state  has  been  diagnosed ;  but  in  time  it  may  be 
taken  advantage  of  by  more  or  less  normal  ambulants,  working  women  for 
example,  who  ought  to  rest  during  the  last  weeks  of  pregnancy,  but  who 
are  unable  from  financial  reasons  to  do  so,  and  by  the  patients  who  clamour 
for  admittance  to  our  maternities,  but  who  are  told  to  come  back  again  when 
the  "  pains  have  begun."  It  is  worth  while  for  us  to  realise  that  practically 
no  provision  is  made  in  existing  hospitals  for  pregnant  women.  In  general 
hospitals,  cases  of  morbid  pregnancy  (for  example,  hyiieremesis  gravidarum) 
are  sometimes  received  and  treated,  but  mostly  under  protest,  lest  there 
occur  a  birth  in  the  wards.  In  maternities,  pregnant  women  are  not 
welcome  much  before  the  full  term  of  gestation,  for  obvious  or  easily 
ascertained  reasons.  Such  patients  would  be  received  into  the  pre-maternity  ; 
it  would  be  their  special  ho.spital.  When  labour  pains  came  on,  they  would 
be  transferred  to  the  adjoining  maternity,  and  it  would  therefore  be  advis- 
able that  the  two  buildings  communicated,  by  a  covereil  way,  for  example. 
A  system  of  linked  hospitals  ! 

The  idea  of  a  pre-maternity  hospital  has  been  forced  into  my  mind  by 
several  circumstances  during  the  last  few  years,  but  more  particularly  by 


468  ANTKN.VIAI.    I'Al  H()I.()(;V    AM)    inClKNE 

i-oiumunio:iti(ins  wliicli  I  have  receiveil  fruiii  inoiliciil  men  in  various  parts 
(if  this  country  ami  tlie  United  States.  Jn  tliese  CDmrnuiiicatinns  tlie  par- 
ticulars of  cases  of  antenatal  disease  and  deformity  were  stated,  and  an 
opinion  asked  for  with  regard  to  possiljle  plans  of  tri^atment.  Tn  some  I 
was  able  to  give  advice,  in  others  I  had  to  confess  that  I  had  little  or 
nothinf;  to  propose  ;  hut  in  all  I  could  not  help  wishing  that  I  knew  of  a 
hospital  where  the  ease  <'oiild  be  ]>laced  and  scientifically  investigated.  The 
iir.st  case  which  powerfully  imi>ressed  me  was  one  nf  recurrent  abortion,  .so- 
called  habitual  miscarriage,  in  which  there  was  no  evident  and  sulKcicnt 
cause  for  the  tendency  which  the  uterus  had,  on  the  slightest  provocation, 
or  on  really  no  provocation  at  all,  to  exjiel  its  contents.  Had  the  patient 
been  in  circumstances  that  would  have  iiermitted  it,  I  should  have  recom- 
mended her  to  go  into  a  nursing  home  for  the  dangercms  period  in  preg- 
nancy, and  not  only  have  treatment  with  chlorate  of  iiotash,  but  have  also 
her  various  excretions  and  functions  thoroughly  investigated,  so  as,  if 
possible,  to  ascertain  the  cause  of  the  special  "  uterine  irritability."  Another 
patient  who  might  have  benefited  by  such  a  hospital  as  I  imagine  the  pre- 
maternity  might  be,  was  the  subject  of  hyperemesis  gravidarum,  which 
terminated  fatally  after  twin  foetuses  had  been  expelled  from  the  uterus. 

I  cannot  help  thinking  that  the  investigation  of  such  cases  in  the  pre- 
maternity  might  lead  to  the  adoption  of  a  more  scientific  method  of 
management  than  the  artificial  induction  of  abortion,  wdiich,  of  course, 
entails  therapeutic  foeticide.  In  fact,  one  of  the  principles  of  the  pre- 
maternity  would  be  the  conservation  of  fa?tal  life,  although,  of  course,  not 
at  the  expense  of  maternal  safety ;  the  residt  aimed  at  would  be  the  con- 
tinuance of  the  pregnancy  with  safety  to  the  mother ;  that  would  be  the 
ideal.  Then  there  have  been  several  cases  of  albuminiiria  in  pregnancy,  all 
of  which  would,  1  am  certain,  have  been  fit  and  pro]ier  jiatients  fiir  the 
pre-materuity ;  several  of  them  developed  eclampsia,  and  in  one  of  them 
albumin  appeared  in  the  urine  for  the  first  time  the  night  before  the  con- 
vulsions manifested  themselves.  In  a  pre-maternity  we  might  be  able  to 
study,  with  scientific  exactness,  not  only  the  pre-eclamptic  but  also  the 
pre-albuminuric  modifications  of  the  urine,  and  we  might  also  discover  the 
relationship  which  exists  between  the  absence  of  normal  thyroirl  hypertrophy 
and  the  presence  of  albumin  in  the  urine.  In  one  of  the  cases  of  eclampsia 
that  I  have  met  with  during  the  last  twelve  months,  the  urine  kept  for 
nine  mouths  without  showing  any  signs  of  putrefaction,  and  without  giving 
any  positive  results  on  the  ordinary  culture  media ;  this  case  would  have 
been  a  suitable  one  for  such  scientific  inve.stigation  as  could  have  been  given 
to  it  in  a  pre-maternity. 

The  cases  to  which  I  have  referred  were  instances  of  the  pathology  of 
pregnancy  in  w-hich  the  maternal  factor  was  of  primary  importance,  and  in 
which  the  treatment  aimed  at  the  safety  of  the  mother ;  but  there  were 
others  in  which  it  was  antenatal  therapeutics  that  came  uniler  consideration. 
There  was  the  case  of  an  alcoholic  mother  who  had  given  birth  to  an  infant 
with  congenital  heart  disease  (persistence  of  the  patency  of  the  foramen 
ovale),  and  who  was  again  pregnant;  the  obvious  treatment  was  tot-al 
abstinence  from  alcohol,  a  treatment  which  might  have  been  carried  out 
with  some  chance  of  success  in  a  special  hospital.  There  was  the  luemo- 
philic  mother  who  had  given  birth  to  two  hemophilic  male  infants,  and  had 
suffered  from  dangerous  jmsf -pari urn  hasmorrhage  on  each  occasion,  and  who 
was  given  calcium  chloride  during  the  last  three  months  of  the  third  ]  reg- 
nancy,  in  the  hope  of  preventing  the  j^sf-parti/m  bleeding,  and  perchan,  e  of 
benefiting  the  foetus.     There  was  the  case  of  the  woman  who  had  p  ven 


PRE-MATERNITV    HOSPITAL  469 

birth  to  a  series  of  very  large  children,  dcail-horii  on  account  of  their  great 
size  ;  in  the  pre-maternity  the  effect  of  variations  in  the  niatorual  diet  (as 
suggested  by  Prochownick  and  others)  upon  the  bulk  of  the  fatus  might 
be  carefully  tried.  The  same  remark  applies  to  cases  of  narrow  pelvis,  in 
which  a  small  infant  might  pass  safely,  while  a  larger  one  would  have  to  be 
sacrificed  or  be  extracted  prematurely,  or  born  by  the  Caesarean  section  at 
term.  There  was  the  case  of  the  patient  who  had  in  previous  pregnancies 
given  birth  to  imbecile  or  mentally  defective  children,  and  to  whom  phos- 
[ihorus  was  given  with  the  apparent  result  that  the  next  infant  was  normal 
in  these  respects.  Finally,  there  was  the  case  of  the  woman,  truly  a 
monstripara,  who  had  brought  three  monstrous  fcetuses  into  the  world,  and 
had  had  several  abortions ;  she  was  willing  to  do  almost  anything  that 
might  be  recommended,  in  the  hope  of  having  a  more  satisfactory  reproduct- 
ive record  ;  she  would  undoubtedly  have  entered  the  pre-maternity,  even  if 
but  little  hope  of  betterment  were  held  out  to  her. 

The  number  of  cases  which  might  be  benefited  by  the  systematic  and 
scientific  investigation  of  the  bodilj'  functions  in  pregnancy,  might  easily  be 
increased ;  but  I  have  cc.intented  myself  with  a  reference  to  the  actual 
instances  which  have  been  brought  under  my  notice  recently.  I  have  em- 
phasised the  scientific  value  of  such  a  hospital  as  the  pre-maternity  might 
be  ;  but  the  more  distinctly  economic  aspects  are  not  to  be  lost  sight  of, 
especially  if  it  be  found  to  be  true  that  working  women  who  are  able  to  rest 
for  the  last  month  or  two  of  pregnancy  give  birth  to  larger  and  more  healthy 
infants.  I  have  not  gone  into  the  question  of  the  management  of  this  as 
yet  imaginary  hospital,  nor  into  the  matter  of  the  medical  staff ;  but  from 
the  scientific  standpoint  there  would  have  to  be  every  appliance  for  the 
perfection  of  antenatal  diagnosis  (skiagraphy,  cephalometry),  and  one 
member  of  the  staff  would  require  to  be  a  skilled  physiological  chemist. 
That  there  will  be  difficulties  in  the  way  may  be  expected ;  that  the  idea 
will  be  regarded  as  visionary  or  chimerical  is  certain,  and  will  not  sur- 
prise me,  as  it  has  been  only  by  slow  degrees  that  I  have  come  to  regard 
it  as  anything  else.  In  the  meantime,  this  communication  may  be  looked 
upon  as  a  "  ballon  d'essai,"  the  whole  matter  of  the  pre-maternity  being  still 
in  niibihus. 

Since  I  published  the  plea  for  a  pre-maternity  hospital,  I  have 
become  still  more  impressed  with  the  need  there  is  for  the  hospital- 
isation of  the  iDregnant  woman.  The  idea  of  a  special  hospital 
attached  to  each  maternity  may  be  chimerical,  but  there  might  at 
least  be  a  ward  or  some  beds  set  apart  for  the  special  treatment 
of  diseases  of  pregnancy.  That  this  would  be  beneficial  for  the 
maternity  hospital  itself,  I  do  not  doubt.  jMany  of  the  fatal  cases 
which  occur  in  our  maternities  at  present  are  due  to  complications  of 
pregnancy  {e.g.,  eclampsia,  albuminuria)  which  have  arisen  before  the 
admission  of  the  patients.  There  can  be  no  doubt,  further,  that  a 
patient  who  has  passed  through  a  morbid  pregnancy  will  be  more 
liable  to  a  bad  labour  than  one  in  whom  the  changes  of  the  wonderful 
gestation  period  have  been  accomplished  in  a  physiological  fashion. 
Even  when  the  pregnancy  has  been  fairly  normal,  some  preparation 
for  the  fast  approaching  labour  and  puerperium  would  not  be  amiss. 
Pregnancy  is  a  great  strain  upon  the  resources,  anatomical  and 
pi  ysiological,  of  the  body ;  and  labour  is  the  crowning  test  of  a 
woman's  strength;    yet   in  too  many   cases    the    parturient  patient 


470  ANll'.NAI'AI.    I'ATHOI.OCV   AND    I  l^(;i  I'.XK 

comes  to  the  liiitli  with  little  or  no  prei)aiciti<iii  at  all.  A  pre- 
niateniity  hosjiital  or  a  ward  in  the  maternity  fur  the  diseases  of 
pregnancy  would  make  it  possible  for  a  woman  who  was  ill  during 
gestation  to  get  the  Ijest  treatment,  and  so  to  fall  in  lahdur  under 
better  conditions  than  could  otherwise  have  been  obtained  for  her. 
More  would  soon  be  learned  regarding  both  the  pathology  and  the 
physiology  of  pregnancy ;  and  u  gratifying  fall  in  the  mortality  lists 
of  the  hospital  could  scarcely  fail  to  follow.  The  maternity  hospital 
might  then  hope  to  attain  more  nearly  to  its  ideal  state,  that  of  a 
hospital  with  two  patients,  mother  and  infant,  to  each  bed.  Sepsis  is 
admittedly  one  of  the  great  causes  of  hospital  deaths,  and  it  is  clear 
that  there  would  be  less  risk  of  it  if  patients  were  admitted  before  the 
labour  was  in  thi^  second  stage,  and  while,  therefore,  there  was  still 
the  opportunity  of  thoroughly  cleansing  the  genitals. 

Since  Novemlier  1,  1901,  through  the  liberality  of  an  anonymous 
donor,  a  bed  has  been  endowed  in  the  Edinburgh  lloyal  Maternity 
and  Simpson  Memorial  Hospital  for  the  study  of  the  diseases  of 
pregnant  women ;  there  have  already  (Deceml:>er)  been  in  it  (under 
the  care  of  I'rofessor  A.  E.  Simpson  and  myself)  several  interesting 
cases  of  disease  in  pregnancy,  including  one  of  hydramnios  and  twins, 
another  of  hyperemesis  gravidarum  with  retrottectiun  of  the  uterus, 
and  another  of  peculiar  convulsions,  regarded  as  of  the  nature  of  petit 
mal,  with  hysteroid  sequelte.  We  have  been  able  to  analyse  the 
urine  in  these  cases  accurately,  to  take  sphygmographic  tracings,  to 
count  the  fcetal  heart-beats,  to  test  reflexes,  to  use  the  cephalometer, 
etc.,  in  a  way  that  was  before  dilHcult  or  impossible.  I  believe  the 
"  Hamilton  bed,"  as  it  has  been  called,  will  very  soon  practically 
demonstrate  its  value,  if  it  has  not  already  done  so. 

At  the  time  when  1  was  writing  my  plea  fur  a  pre-niater- 
nity  hospital,^  other  obstetricians  were  approaching  the  idea  of 
the  hospitalisation  of  pregnant  women  from  other  standpoints. 
I'rofessor  J.  A.  C.  Kynoch  of  Dimdee  {Brit.  Med.  Journ.,  i.  for  1901, 
p.  929)  has  pointed  out  that  homes  for  the  reception  of  pregnant 
women  exist  in  large  towns,  and  it  is  true  that  there  are  such :  but 
they  are  often  of  the  nature  of  reformatories  or  asylums  rather  than 
of  hospitals  in  which  the  medical  care  of  the  patients  is  put  first. 
L.  Bouchacourt  (/,«  Grosscssc ;  jvicricidtxirc  intra-utrrinc,  I'aris,  1901) 
has  traced  the  history  of  the  various  establishments  in  France  and 
Austria  for  the  reception  of  pregnant  women,  and  has  argued 
strenuously  for  the  creation  of  numerous  "  sanatoriums  de  grossesse." 
The  "  Secret  ^laternity  "  of  Prague  seems  to  have  been  the  first  of 
these  "sanatoriums,"  for  it  was  founded  in  1789,  but  it  was  veiy 
different  from  what  is  understood  by  the  "  sanaturium  de  grossesse" 
of  the  present  day.  Into  it  pregnant  women  were  received  on  the 
payment  of  a  fee,  and  neither  their  religion  nor  their  social  position 
nor  their  nationality  were  inquired  into.  In  I'aris,  also,  there  were 
beds  for  needy  pregnant  women  in  connection  with  some  of  the 
obstetric  clinics ;  but  they  were  too  often  occupied  by  strong  and 

'  I  liad   ]iievioii.sly  mooted  the  subject  in  a  tentative  fiisliion  euilv  in  1900  {SaiU. 
Med.  and  Surg.  Juani.,  vi.  i76,  1900). 


I  HYGIENE   OF    I'lU'.ClNANCY  471 

liealth)'  young  women  wlio  could  render  service  as  cooks  and  waslier- 
wonien.  In  1885  the  "  asile  de  nuit  de  la  rue  Saint-Jac(jues  "  was 
increased  by  the  addition  of  a  ward  containing  sixteen  beds  for 
pregnant  women,  and  similar  institutions  are  to  be  found  both  in 
I'aris  and  in  other  large  towns ;  but  they  are  often  of  the  nature  of 
reformatories  or  "  maisons  de  correction,"  and  their  sanitary  condition 
lius  seldom  given  satisfaction.  In  Paris  the  first  "  sanatorium  de 
grossesse,"  in  the  proper  sense  of  the  word,  was  not  founded  till 
1892;  it  was  called  the  "Eefuge  de  I'avenue  du  Maine,"  and  it 
received  thirty-six  pregnant  women  who  required  to  rest.  Since 
then  several  other  sanatoriunis  of  the  same  kind  have  beeii  estab- 
lished ("  asile  public  pour  femmes  enceintes,"  "  asile  maternel,"  "  asile 
.Sainte-Madeleine,"  etc.).  These  institutions  have  done  good  service, 
especially  in  the  case  of  working  women,  who  were  thus  enabled  to 
rest  during  the  last  month  of  pregnancy;  and  Pinard  {Ann.  dc  gynt'c, 
1.  81,  1898)  has  shown  that  the  infants  of  these  patients  weighed 
more  than  those  of  pregnant  women  who  had  to  work  for  their  living 
up  to  the  onset  of  labour  pains.  All  these  facts  are  very  interesting, 
but  in  the  idea  of  the  pre-maternity  hospital  I  aim  at  something  more 
than  is  accomplished  by  any  of  these  existing  institutions.  I  look 
forward  to  a  specially  set  apart  hospital  for  the  treatment  of  diseases 
of  pregnancy,  with  a  medical  stafl'  capable  of  carrying  on  all  kinds  of 
research,  and  with  all  the  known  means  of  diagnosing  and  treating 
both  the  pregnant  woman  and  her  unborn  child.  I  am  fully  con- 
vinced that  the  only  way  to  establish,  on  a  sure  foundation,  the  pre- 
ventive treatment  of  the  diseases  of  pregnancy  and  of  the  unborn 
infant,  is  by  the  institution  of  pre-maternity  hospitals  or  pre- 
maternity  wards  in  maternity  hospitals.  Under  the  title  "  la  defense 
do  I'cnfant"  Ollive  and  Schmitt  {Gaz.  hehd.  d.  sc.  med.,  xxii.  478,  1901) 
enumerate  many  ways  in  which  the  health  of  the  new-born  is  to  be 
preserved  ;  among  these  the  pre-maternity  hospital  must  surely  find 
a  place.  "  La  defense  de  I'enfant  est  a  I'ordre  du  jour,"  writes 
]\Iaygrier  {L'Ohstcii-iqiie,  yi.  481,  1901);  but  it  is  necessary  to  begin 
with  "  la  defense  du  fcetus." 

Hygiene  of  Pregnancy. 

As  has  already  been  pointed  out,  treatment  of  the  fa?tus  must 
be  primarily  maternal ;  so,  to  maintain  the  hygiene  of  antenatal  life 
one  must  maintain  the  hygiene  of  pregnancy.  This  is  the  true 
environmental  treatment  of  the  unborn  infant ;  this  is  one  aspect  of 
puericulture.  Most  of  the  text-books  of  Obstetrics  give  a  chapter  or 
part  of  a  chapter  to  the  management  of  pregnancy ;  but  in  many  of 
them  the  advice  consists  laigely  in  the  recommendation  that  all  the 
laws  of  health  which  applj^  to  the  non-pregnant  condition  should  be 
specially  enforced  in  the  pregnant  state.  This  is,  of  course,  quite 
true ;  but  it  is  too  often  interpreted  by  the  profession  and  the  public 
as  permission  to  the  pregnant  woman  to  continue  disregarding  many 
of  the  laws  of  health  just  as  she  did  when  non-pregnant.  As  I  have 
said  already,  pregnancy  is  a  severe  strain  upon  the  whole  system. 


472  ANTKXAT.M.    I'AIIIOI.OdV    AND    I  I^C.IKNK 

and  weaknesses  wliich  were  unrevealed  nr  unnoliceil,  as  a  result  <>( 
hygienic  errors  jnior  Ui  gestation,  may  give  rise  to  gia\e  dangers  in 
pregnancy.  For  instance,  the  kidneys  may  he  somewhat:  (hseased, 
and  yet  cause  the  woman  no  inconvenience ;  hut  under  the  strain  of 
their  increased  activity  in  pregnancy,  with  perliaps  the  special  tax  of 
a  full  meal  of  proteids,  they  may  fail,  and  eclampsia  l>e  induced. 
Constipation,  which  may  apparently  cause  no  ill  effects  in  the  non- 
pregnant state,  may  set  uj)  a  toxaemia  in  pregnancy.  The  result  of 
all  this  is  that,  while  we  occasionally  meet  with  a  normal  jiregnancy, 
we  too  often  have  sadly  to  admit  that  pregnancy  frequently  is  not 
strictly  physiological.  It  ought  to  he  so,  hut  it  is  not.  Tliat  the 
fo'tus  suffers  no  more  than  it  does,  is  probably  due  to  the  wonderful 
regulating  mechanism  which  tends  to  counteract  errors  and  to 
prevent  ill  etlects. 

As  a  matter  of  fact,  the  profession  does  not  understand  the 
physiological  changes  of  pregnancy,  possibly  does  not  believe  in  their 
existence  or  in  their  inip(jrtance.  There  are,  however,  popular 
notions  on  the  subject,  and  these  overshadow  the  scientific  ideas  and 
cover  them  as  with  a  mantle  of  fog,  through  which  some  few  well- 
ascertained  facts  loom  forth  dimly  to  be  discerned.  Thus,  the 
popular  mind  has  opinions  on  diet  in  pregnancy,  on  the  power  of 
maternal  impressions,  on  exercise,  on  sea-bathing,  etc.,  and  these  are 
often  far  from  correct,  but  pass  as  truth  because  the  profession  does 
not  very  actively  contradict  them  or  replace  them.  Of  late,  however, 
there  have  been  some  signs  of  lifting  of  the  fog  curtain,  and  here  and 
there  some  things  are  coming  into  sight,  and  others  are  losing  tliat 
unnatural  magnitude  which  fog-shrouded  objects  often  show.  There 
is  a  freshening  breeze  of  scientific  investigation,  and  the  mists  are 
rolling  slowly  away.  The  light  that  may  come  from  the  pre- 
maternities  of  the  future  may  wonderfully  dissipate  these  fogs. 

Diet  in  Pregnancy. 

,^  Let  us  take  a  few  examples  of  these  popular  beliefs.  Tiicre  is, 
nBinstance,  the  question  of  diet  in  pregnancy.  The  popular  advice 
to  the  pregnant  woman  is  to  eat  "  enough  for  two,"  and,  as  generally 
and  confidently  interpreted,  this  means  to  eat  double  the  usual 
amount ;  and  it  may  be  safely  said  that,  if  this  injunction  be  carried 
out,  too  much  is  eaten.  Even  supposing  for  a  moment  that  the 
dietetic  dilliculties  of  pregnancy  could  thus  he  got  over  in  this 
arithmetical  fashion,  to  be  logical,  the  jiopular  advice  ought  to  be  to 
eat  enough  for  one  and  a  varying  fraction  of  one,  namely,  at  the  mid- 
term of  pregnancy,  enough  for  one  and  one-hundred-and-twelfth  of  one. 
Since,  however,  most  healthy  persons  habitually  eat  more  than  enough 
for  one,  it  may  reasonably  be  concluded  that  the  pregnant  woman 
who  eats  heartily  consumes  quite  sufficient  food  to  supply  tlie  wants 
of  herself  and  her  fraction.  That  there  is  a  real  and  not  a  visionary 
danger  in  the  application  of  such  popular  advice,  is  borne  out  by 
cases  like  that  reported  by  liarton  Cooke  Hirst  ( Tiji-Boolc  of  OhftMrics, 
p.  189, 1900),  in  whicli  a  woman  took  two  quarts  of  nnlk  a  day  between 


DIET    IN    PREGNANCY  473 

meals,  ami  was  confined  (with  difficulty)  of  a  child  weighing  11  i|  lbs. ; 
and  by  the  results  of  experiments  u])on  the  lower  animals.  D.  Noel 
I'aton  has  found  that,  in  the  case  of  well-fed  pregnant  guinea-pigs, 
each  gnu.  of  mother's  weight  produced  from  O'-l  to  0o5  grm.  of 
young,  while  in  the  case  of  an  under-fed  animal,  each  grm.  of  the 
mother  only  produced  0-22  grm.  of  young. 

With  regard  to  the  quality  of  her  food,  the  popular  belief  as  to  the 
pregnant  woman  is  that  she  must  get  what  she  "  longs  for,"  otherwise 
her  unborn  infant  will  suffer.  Now,  it  is  quite  possible  that  under- 
lying the  "  longings  "  of  pregnant  women  for  certain  articles  of  food 
(sometimes  neither  nutritious  nor  nice),  there  is  a  true  physiological 
need  which  thus  finds  expression  (a  sort  of  inarticulate  crying  out  of 
the  tissue  for  acids  or  alkalies),  yet  in  the  great  majority  of  cases  no 
such  dietetic  necessity  lies  patent  or  latent.  Further,  there  is  no 
valid  scientific  evidence  that  the  refusal  of  "  longed-for  "  snacks,  con- 
sisting of  peppercorns  and  raw  oatmeal,  or  other  dietetic  eccentricities, 
will  result  disastrouslv  to  the  unborn  infant  (A.  (liles,  Trans.  Obst. 
Soc.  Loiul,  XXXV.  242,  1893). 

Within  recent  years,  signs  have  not  been  wanting  that  popular 
beliefs  as  to  the  cj^uautity  and  quality  of  the  food  of  the  pregnant 
woman  were  to  be  soon  replaced  by  scientific  views.  Apparently, 
many  obstetricians  are  afraid  of  giving  an  opinion  on  such  matters ; 
but  L.  I'rochownick  of  Hamburg  (Ccntrlhl.f.  Gynilh.,  xiii.  577,  1889  ; 
Thcraj}.  MonafsL,  xv.,  Hft.  8,  9,  1901)  and  others  (H.  Florschiitz, 
A.  Hoflraann,  J.  Eeijenga,  J.  Haspels,  v.  Swiecicki,  Josephson, 
J.  F.  W.  Donath,  Hegele,  Leusser,  G.  Beck,  F.  Horn,  E.  Fraeukel, 
E.  Preiss,  and  Meurer)  have  gone  much  further,  and  have  modified 
the  diet  of  pregnant  women  in  such  a  way  as  to  produce  definite 
effects  both  upon  the  mother  and  the  fcetus.  Prochownick  and  his 
followers  believe  that  by  altering  the  diet  in  pregnancy  it  is  possible 
to  infiuence  the  character  of  the  confinement,  of  the  puerperium,  and 
of  lactation,  as  well  as  the  state  of  development  of  the  foetus.  Thus, 
by  dieting  aniemic,  chlorotic,  or  fat  and  weak  women,  it  has  been 
found  possible  to  give  them  more  normal  obstetric  experiences,  and 
to  give  them  back  the  power  (which  they  had  lost)  of  nursing  their 
infants.  But  it  is  specially  with  the  effect  of  diet  upon  the  foetus 
that  we  are  here  concerned.  In  cases  of  pelvic  contraction  between 
3]  and  4  inches,  Prochownick  shows,  by  a  series  of  forty-eight  cases 
representing  sixty-two  confinements,  that  maternal  diet  can  so 
influence  the  size,  weight,  and  osseous  development  of  the  foetus,  as 
to  make  it  possible  for  it  to  be  born  normally  at  the  full  term, 
whereas,  in  previous  pregnancies,  instrumental  means  or  the  induction 
of  premature  labour  were  necessary.  The  cases  included  seventeen 
of  Prochowuick's  own,  and  thirty-one  under  the  care  of  Haspels, 
v.  Swiecicki,  Eeijenga,  and  the  others  mentioned  above.  The  recom- 
mendation was  that  the  mother  take  during  the  last  two  or  three 
months  of  her  pregnancy  the  following  diet : — For  breakfast,  a  small 
cup  of  coftee  (100  c.c),  about  25  grms.  of  biscuit  or  bread  with  some 
butter.  For  dinner,  any  kind  of  meat,  an  egg,  fish  with  a  little 
sauce,  green  vegetables  prepared  in  fat,  salad,  cheese.     Supper,  the 


II 


474  AN  ri'.N.Vr.M.    I'MIIOLOCII-    AM)    Il^dll'.NF. 

same  as  for  dinner,  with  40  to  50  i,'rnis.  of  liread  and  butler  at 
pleasure.  Water,  soups,  potatoes,  puddings,  suj,'ar,  and  beer  are  quite 
forbidden;  from  .'iOO  to  400  c.c.  of  red  wine  or  moselle  is  to  be  drunk. 
Slight  alterations  were  permitted  to  suit  individual  tastes,  such  as 
the  sulistitution  of  small  quantities  of  milk  and  water  for  the  alcohol, 
along  with  fresh  fruit.  Further,  a  small  cujj  of  tea  or  cottee  may  be 
taken  in  the  afternoon,  with  15  to  20  grms.  of  bread  or  one  egg. 
The  total  daily  quantity  of  iluid  was  not  to  exceed  500  c.c. 

So  far  this  dietetic  treatment  has  been  used  for  the  definite  pur- 
pose of  diminishing  the  bulk  of  tlie  foetus  and  delaying  the  ossifica- 
tion of  the  cranial  bones,  so  as  to  allow  its  passage  through  a  narrow 
pelvis ;  but  its  range  of  applicability  is  not  limited  to  these  cases. 
It  might  conceivably  be  useful  in  women  who,  with  normal  pelves, 
had  gi\-en  birth  repeatedly  to  infants  so  large  and  well  developed  as 
to  die  in  birth  simply  on  account  of  tlieir  bulk  and  advanced  ossifica- 
tion. It  might  also  be  valualile  in  instances  of  prolonged  pregnancies 
with  post-mature  fuetuses,  as  well  as  in  cases  of  fcetal  disease  and 
congenital  debility. 

Having  enumerated  these  po.ssible  therapeutic  extensions  of  the 
dietetic  treatment,  I  must,  however,  point  out  certain  difiiculties 
which  lie  in  the  way.  There  is,  first  of  all,  the  question  whether  it 
is  possible  to  slacken  nutrition  in  the  ftttus  without  delaying  develop- 
ment. In  other  words,  are  the  infants  born  at  the  full  term  mature 
in  every  respect  save  size  and  weight,  or  do  their  internal  organs,  etc., 
show  the  characters  of  the  sixth  or  seventh  month  of  antenatal  life  ? 
Are  they  full  time  babies  save  in  size,  or  premature  infants  except  in 
age  ?  Then  there  is,  second,  the  difficult  problem  of  ftetal  nutrition 
upon  which  I  have  already  written  at  some  length  (ride  pp.  152-159). 
There  is  evidence  to  show  that  in  the  later  months  of  pregnancy, 
at  any  rate,  the  fa>to-maternal  metabolism  is  of  a  most  intricate  kind, 
and  that  the  placenta  is  far  from  being  the  simple  transmitter  of 
pai'ticles  (nutritious  or  excrementitious)  as  has  in  the  past  been 
believed.  There  is  sufficient  proof  forthcoming  of  the  selective 
powers  of  the  placental  epithelium  to  enable  us  to  state  that  the 
transplacental  interchanges  are  not  governed  solely  l)y  the  laws  of 
osmosis  as  they  are  understood  by  the  jihysicist.  The  fietus,  also,  has 
a  metabolism  which  is,  to  some  extent,  independent  of  that  of  the 
mother :  its  tissues  are  assimilating  and  functioning  at  a  different 
rate,  and  perhaps  even  in  different  ways,  from  the  homologous  tissues 
in  the  mother.  To  put  it  in  somewhat  more  popular  language,  the 
imborn  infant  may  have  a  better  or  a  worse  digestion  than  his  mother. 
Taking  all  tliese  matters  into  account,  as  well  as  others  to  which 
reference  has  been  already  made  [ride  pp.  152-159),  the  question  of 
f(etal  nutrition  becomes  very  obscure,  and  its  relation  to  the  diet  of 
the  pregnant  woman  cannot  be  simple.  We  cannot  by  overfeeding  a 
woman  make  sure  that  she  will  give  birth  to  a  large,  fat  child ;  at 
the  same  time,  there  must  be  a  relation  between  fcetal  and  maternal 
nutrition,  and  the  state  of  the  maternal  health  must  have  an  influence, 
determined  by  laws,  albeit  undiscovered  laws,  upon  the  size  and 
development  of  tlie  fatus.     In   the  meantime,  there  is  no  need  to 


OCCUPATION    IX    I'REONANCY  475 

suspend  all  attempts  to  influence  the  development  of  the  unborn 
infant  by  modifying  the  maternal  diet;  rrochownick's  treatment 
must  lie  tried  and  its  results  tested ;  we  cannot  afford  to  wait 
till  we  understand  all  the  details  of  the  action  of  renredies  or  other 
therapeutic  measures;  if  they  give  good  results,  we  use  them  empiric- 
ally, hoping  later  to  clear  up,  in  a  scientific  way,  the  rationale  of 
their  employment.  Further,  we  must  surely  rejoice  that  there  is 
some  slight  but  perceptible  lifting  of  the  fog  curtain  hanging  over  the 
subject  of  diet  in  pregnancy ;  nevertheless,  we  must  hasten  slowly, 
for  with  such  a  fog  and  that  continual  lee-shore  of  the  unknown 
physiological  reaction  of  the  foetus  so  close  at  hand,  it  will  be  well  if 
our  theories  carry  very  little  sail. 

Occupation,   Exercise,  etc.,   in  Pregnancy. 

Another  means  of  maintaining  the  mother's  health  in  pregnancy, 
and  so  of  mauitaining  also  the  foetal  well-being,  is  to  regulate  the 
occupations  in  which  the  pregnant  woman  may  engage.  This  matter 
has  been  already  referred  to  in  Chapter  XV.  in  connection  with  foetal 
poisoning  with  lead,  mercury,  phosphorus,  etc.,  and  it  is  now  fairly 
well  recognised  that  there  are  trades  which  are  so  dangerous  that 
expecting  mothers  ought  not  to  be  allowed  to  engage  in  them 
(Brit.  Med.  Journ.,  i.  for  1900,  p.  718).  Further,  it  is  doubtful 
whether  women  who  are  within  a  month  of  their  confinement  should 
be  allowed  to  do  hai'd  manual  laliour  of  any  kind ;  it  ought  to  be 
obligatory  upon  them  to  rest  in  the  last  four  weeks  of  gestation  (in 
Switzerland  this  is  insisted  on  by  law),  and  there  should  be  provision 
made  for  them  ("  uue  indemnito'  de  grossesse  ").  A  pregnant  woman 
ought  to  take  sufficient  exercise  to  keep  her  body  in  health ;  but 
excessive  exertion,  whether  in  the  form  of  bicycling  (24),  or  of  walk- 
ing, or  of  golfing,  or  of  dancing,  or  of  household  work,  should  be 
forbidden.  The  clothing  should  be  hygienic,  and  abdominal  com- 
pression should  be  prevented ;  for  there  is  some  evidence,  although  it 
is  not  very  strong,  that  coi'set-pressure  may  act  injuriously  upon  the 
foBtus  in  utero.  The  pregnant  woman  ought  to  be  encouraged  to 
think  lightly  of  the  possil)le  effects  of  so-called  "  maternal  impres- 
sions," and  to  be  strengthened  by  the  assurance  that  there  is  no  real 
scientific  evidence  of  their  potency  to  deform  her  infant.  This  sub- 
ject, however,  wiU  be  dealt  with  in  detail  when  I  come  to  describe 
malformations  and  monstrosities  (Pathology  of  the  Embryo).  The 
question  of  permitting  tooth-extraction,  long  railway  journeys,  small 
surgical  operations,  and  sexual  connection  during  pregnancy,  usually 
arises  in  relation  to  the  production  of  abortion  or  premature  labour. 
In  attempting  to  give  an  answer,  each  case  must  largely  be  decided 
on  its  own  merits ;  for,  as  I  have  already  shown,  some  women  will 
abort  on  the  slightest  possible  provocation,  having  a  high  degree  of 
"  uterine  irritability " ;  others  may  be  subjected  to  severe  accidents 
without  the  interruption  of  pregnancy.  But,  apart  from  the  produc- 
tion of  abortion  or  premature  labour,  it  is  sometimes  a.sked  whether 
much  travelling  or  regular  sexual  intercourse  during  pregnancy  will 


476  AXTKXATAI.    I'ATHOI.OdV    AND    inCll'.NK 

have  any  iiijuridus  ellbcls  upon  tlie  fd'tus.  Tt  is  difHcult  to  give 
answer  to  this;  and  in  the  present  state  of  our  knowledge  it  is  safest 
to  confess  our  ignorance,  and  to  take  precautions  erring  on  the  side 
of  safety. 

The  use  of  certain  medicines  is  to  be  prohibited  to  pregnant 
women ;  among  these  are  ergot,  quinine,  and  all  the  direct  aborti- 
facients,  as  well  as  powerful  purgatives,  especially  of  the  saline  kind. 
Further,  alcohol  in  excess  must  be  forbidden,  and  all  habits,  such  as 
the  craving  for  morphia  or  cocain,  sternly  coml)ated.  Finally,  all 
pathological  states  of  the  mother  arising  during  pregnancy  should  be 
treated  in  accordance  with  the  Ijest  i)rinciples  of  therapeutics ;  in 
order  that  this  may  be  done,  they  must  first,  of  course,  be  recognised, 
and  for  this  purpose  the  regular  testing  of  the  urine  for  albumin  is 
one  very  necessary  precaution.  The  more  smoothly  and  normally 
tlie  pregnancy  runs  its  course,  the  more  chance  tiie  foetus  will  have 
of  coming  into  the  world  healthy  and  well  nourished,  always  suppos- 
ing, of  course,  that  it  came  into  tlie  fujtal  period  of  antenatal  life  out 
of  a  normal  embryonic  and  germinal  existence.  Unfortunately,  that 
cannot  always  be  assured. 

Enough,  howevei',  has  been  said  of  the  value  of  caring  for  the 
foetus  by  caring  for  the  mother.  I  must  now  pass  from  the  environ- 
mental treatment  of  the  f(Ptus  to  the  direct  and  immediate. 

Medication  of  the  Foetus. 

Many  misconceptions  have  gathered  round  the  subject  of  the 
medicinal  ti'eatment  of  the  infant  still  in  utero ;  and  while  some  have 
greatly  exaggerated  the  possibilities,  others  have  greatly  minimised 
them.  From  some  of  the  statements  that  have  been  made  by 
enthusiastic  antenatal  therapeutists,  it  might  be  imagined  that  drugs 
could  be  passed  directly  into  the  unborn  infant  as  one  pours  a  liquid 
from  one  bottle  into  another.  On  the  other  hand,  it  would  seem  as 
if  those  who  are  sceptical  regarding  antenatal  treatment  had  come  to 
believe  that  the  foetal  economy  was  absolutely  separate  from  and 
independent  of  the  maternal.  Now,  as  is  so  often  the  case,  the  truth 
lies  somewhere  between  these  two  extremes. 

Just  as  some  diseases  can  be  transmitted  through  the  mother  to 
the  fcetus,  so  some  drugs  can  be  admmistered  to  the  fcetus  by  admin- 
istering them  to  the  mother.  Just  as  some  diseases  sometimes  fail  to 
affect  the  fcetus  although  they  aifect  the  mother,  so  some  drugs  some- 
times fail  to  reach  the  ftetus  although  they  circulate  freely  in  the 
mother.  Into  both  subjects  the  placental  factor  (ride  p.  179)  enters 
with  most  perplexing  results.  All  tliis,  and  much  more,  the  reader  lias 
doubtless  already  gathered  from  the  perusal  of  Chapters  X.  and  X^^ ; 
but  I  may  here  summarise  our  knowledge  of  the  passage  of  medicines 
from  mother  to  ftetus  in  tiie  following  few  words : — There  is  evidence 
(clinical  and  experimental)  that  not  only  do  the  chemical  substances 
which  make  up  the  fo'tal  body  pass  from  the  woman  to  her  unborn 
infant,  but  that  also  certain  substances,  foreign  to  the  constitution  of 
the  fretus,  sometimes,  and  under  certain  circumstances,  pass  through 


TREATMENT   OK    Fd'/IAL   SYPHILIS  477 

tlie  placental  barriers.  Among  these  last  may  lie  mentioned  arsenic, 
lithium,  mercury,  alcohol,  chloroform,  ether,  morphin,  autipyriu, 
carbolic  acid,  quinine,  and  the  salicylates.  We  do  not  know  in  what 
form  and  in  what  special  combination  any  of  these  substances 
(whether  those,  such  as  phosphorus,  calcium,  soda,  or  potash,  which 
exist  normally  in  the  foetus,  or  those  such  as  mercury  and  morphin, 
which  are  foreign  to  it)  pass  through  the  placenta,  for  the  chemistry 
of  the  freto-maternal  interchanges  is  an  unworked  (almost  unwork- 
able) field  of  research.  Of  fatal  pharmacodynamics,  or  the  jihysio- 
logical  action  of  drugs  on  the  healthy  foetus,  we  also  know  exceed- 
ingly little.  We  must  be  content  in  the  meantime  with  the  know- 
ledge that  some  medicines  pass  to  the  fo'tus. 

At  this  point  it  may  be  well  to  emphasise  the  fact  that  it  is  not 
necessaiy  for  the  drug  to  reach  the  intracorporeal  tissues  of  the 
foetus  in  order  to  influence  it.  It  may,  by  improving  the  mother's 
health,  beneficially  affect  the  fa3tus.  That,  of  course,  is  quite  clear. 
But,  further,  if  it  reach  tlie  placenta,  it  is  already  in  touch  with  the 
foetus,  it  is  indeed  in  one  of  the  foetal  organs ;  for  the  placenta  is 
part  foetal  as  well  as  part  maternal.  Possibly  it  is  in  this  manner 
that  mercury  and  chlorate  of  potash  act  upon  foetal  disease.  The 
presence  of  the  drug  in  the  placenta  may  produce  its  beneficial  effect 
simply  by  prolonging  pregnancy  to  its  natural  term ;  the  placental 
integrity  is  maintained,  and  abortion  or  premature  labour  avoided. 
Or  it  may  increase  the  bactericidal  or  resisting  or  selective  powers 
of  the  placental  tissues,  and  so  influence  for  good  the  foetus  which  is 
so  dependent  upon  the  placenta  for  life  and  health.  At  any  rate,  it 
is  very  necessary  to  keep  this  fact  in  mind  in  judging  of  clinical 
evidence  or  experimental  results. 

It  may  be  well  now  to  consider  some  specific  cases  of  foetal 
therapeutics  by  medicinal  substances.  The  treatment  of  foetal 
variola,  malaria,  general  dropsy,  and  one  or  two  other  morbid  states, 
has  been  referred  to  already,  and  will  not  be  given  here. 

Treatment  of  Foetal  Syphilis. 

The  treatment  of  the  foetus  for  syphilis  may  be  necessary  in 
several  possible  circumstances.  In  the  first  place,  the  pregnant 
woman  may  herself  show  evident  signs  of  syphilis ;  in  the  second 
place,  the  father  of  her  foetus  may  be  syphilitic,  but  she  herself  may 
show  no  sign  of  it ;  and,  in  the  third  place,  the  condition  of  the 
father  may  be  doubtful  or  unknown,  and  the  only  signs  of  syphilis  in 
the  mother  may  have  been  tlie  previous  occurrence  of  a  series  of 
abortions,  or  premature  labours,  or  dead-births.  In  all  these  cases 
the  rule  is  to  treat  the  foetus  through  the  mother  with  antisyphilitic 
medicines,  for  in  all  of  them  the  foetus  or  the  placenta,  or  both  the 
foetus  and  the  placenta,  are  very  probably  syphilitic.  The  earlier  in 
pregnancy  the  ti'eatment  is  begun  the  better,  and  it  ought  to  be 
continued  to  the  end,  and  then  its  place  taken  by  direct  treatment  of 
the  new-born  infant.  All  writers  are  not  agreed  upon  tlie  second 
and  third  indications  for  antisyphilitic  treatment  referred  to  above, 


478  ANTKXATAI,    I'A  Tl  lOI.OC'i'    AM)    IIVCII-.NK 

and  the  risks  of  adininisteriug  much  mercury  to  a  healthy  mother 
and  fa-tus  liave  been  brought  forward ;  but,  according  to  A.  Fournier 
{L'HMdiW  SfipMlitiquc ,  p.  368,  1891),  these  are  not  great.  The 
results  to  be  expected  are  the  prevention  of  abortion  and  premature 
labour,  of  dead-birtii,  of  placental  disease  and  hydramnios,  of  syphilis 
in  the  infant  at  birth  or  soon  thereafter,  and  of  congenital  debility. 
E.  Fournier  (Sfif/mafrti  iJi/sh-o/i/iiqucs  di-  l'IT('ir)lo-Si//i/iilis,  p.  365, 
1898)  claims  also  that  a  possible  result  may  be  the  prevention  of  the 
dysti'ophies  as  well  as  of  the  other  manifestations  of  antenatal 
syphilis ;  but  this,  altiiough  quite  possilde,  almost  implies  the  com- 
mencement of  treatment  at  the  very  beginning  of  tlie  fietal  period 
(second  month  of  intrauterine  life). 

The  medicine  to  lie  used  is,  of  course,  mercury,  either  alone  or 
in  combination  witli  iodide  of  potassium,  but  ])referably  alone  so 
far  as  its  effect  on  the  fa'tus  is  concerned.  Tlie  preparation  may 
be  that  of  hydrargyrum  cum  creta  in  one-grain  doses;  and  one 
of  these  powders  may  be  given  twice  or  thrice  daily.  Tlie  mer- 
cury may  also  l)e  administered  as  the  iodide,  and  combined  with 
iodide  of  potassium  ;  but  the  advantages  of  the  iodides  are  somewhat 
problematical.  We  cannot  tell  what  proportion  of  the  dose  given 
reaches  the  placenta  and  the  fa-tus,  but  it  is  generally  believed  that 
only  small  quantities  are  necessary  for  the  fietus.  As,  however, 
mercury  is  proverbially  well  borne  by  the  infant,  no  great  anxiety 
need  be  felt  regardmg  the  exact  amount  to  be  transmitted  to  the 
placenta.  Eecently,  the  local  treatment  of  fietal  syphilis  with  mer- 
cury has  been  tested  by  Riehl  (JVicm.  klin.  Wchnsrhr.,  xiv.  627, 
1901),  and  with  apparently  good  results.  Thirty-three  cases  of 
pregnancy  in  women  with  recently  acquired  s}-philis  were  treated 
with  vaginal  pessaries  containing  1  grm.  of  the  German  unguentum 
cinereum  with  1  or  2  grms.  of  oleum  theobromatis.  The  pessaries 
were  introduced  as  far  as  the  vaginal  roof,  and  kept  in  position  with 
a  tampon  soaked  in  glycerine  of  tannin.  It  should  be  remarked  that 
mercury  was  also  given  by  inunctions  or  injections.  In  the  tliirty- 
tiiree  cases  there  were  only  one  abortion  (3  per  cent.)  and  three 
premature  labours  (9  per  cent.)  in  the  eighth  and  ninth  month,  wliile 
aboi'tions  occurred  in  22  per  cent,  of  the  cases  treated  in  the  ordinary 
way  given  in  Fournier's  statistics.  The  number  uf  still-liirths  was 
two,  or  only  6  per  cent.,  and  the  total  number  of  children  (alive 
or  dead)  who  showed  signs  of  syphilis  was  seven,  or  21  per  cent. 
It  will  be  interesting  to  learn  if  Iliehl's  local  treatment  prove 
equally  effective  where  the  ftutal  syphiUs  is  apparently  due  to  the 
father  alone. 

It  need  hardly  be  added  that  the  mercurial  treatment  of  tlie 
infant  after  birth  is  absolutely  necessary,  and  thai  the  treatment  of 
the  mother  should  be  continued  in  view  of  the  occurrence  of  another 
pregnancy,  and  in  order  that  mercury  may  reach  the  child  also 
tlirougli  the  milk.  These  measures,  however,  do  not  fall  under  the 
heading  of  fa>tal  therapeutics  strictly  so  called. 


TREATMENT  OE  I'LACENTAL  DISl'.ASE       470 

Treatment  of  .Recurrent  Placental  Disease. 

The  treatment  of  recurrent  placental  disease,  with  its  frequent 
concomitants,  premature  labour,  still-birth,  or  dead-birth,  is  not  so 
well  established  as  is  that  of  fu?tal  syphilis.  Of  course,  I  refer  here  to 
the  cases  of  placental  disease  in  which  syphilis  can  be  excluded. 

As  Prof.  A.  R.  Simpson  has  pointed  out  {Trans.  Amcr.  Gyncc.  Soc, 
xiii.  413,  1888),  Sir  James  Y.  Simpson,  in  a  clinical  lecture  published 
in  1845  {Lond.  and  Edin.  Month.  Journ.  Med.  Sc,  v.  119),  stated  that 
he  had  kept  patients  constantly  on  small  doses  of  alkaline  salts,  such 
as  chloiate  of  potassa,  in  cases  where  they  had  lost  the  children  of 
previous  pregnancies  from  disease  of  the  placenta,  and  "  apparently 
with  perfect  success."  His  explanation  was  that  the  salt  rendered  the 
blood  more  arterial  and  facilitated  the  interchange  of  gases  in  the 
feeble  placenta.  Sir  James  Simpson  states  that  he  treated  in  this 
way  "  a  great  nmnber  of  cases,"  but  towards  the  end  of  his  life  he 
admitted  that  the  drug  sometimes  failed.  T.  F.  Grimsdale  (Lirerjiool 
Mcd.-Chir.  Journ.,  i.  248,  1857)  also  obtained  good  results,  as  did 
Bruce  {Edinh.  Med.  Journ.,  xi.  669,  1865-6),  A.  IngUs,  Cairns,  J. 
Moir,  and  Keillor  {ibid.,  p.  671),  Cuthbert  {ibid.,  xv.  85,  1870),  J. 
Thorburn  {Liverpool  and,  Manchester  Med.  and  Surg.  Ecp.,  iii.  1,  1875), 
and  A.  E.  Simpson  {loc.  cit.).  I  have  used  it  in  several  cases ;  in  one 
the  success  (as  .judged  by  the  post  lioc  argument)  was  complete,  a 
living  healthy  child  being  born  not  only  not  prematurely,  but  a 
month  beyond  the  full  term ;  in  another  (a  case  of  recurrent  fa^tal 
dropsy)  the  pregnancy  lasted  longer,  but  the  infant  was  still  drop- 
sical ;  and  in  two  others  (recurrent  fa;tal  death),  the  effect  seemed 
to  be  nil.  I  have  given  it  both  alone  and  combined  with  iron.  The 
dose  is  twenty  grains  thrice  daily.  It  would  appear  to  be  specially 
valuable  in  the  cases  in  which  there  are  traces  of  placental  hasnior- 
rhages.  The  results  to  be  expected  are  continuation  of  the  pregnancy 
to  the  full  term,  and  the  birth  of  a  living  infant ;  and  the  drug  may 
perhaps  be  described  as  a  placental  tonic.  E.  Lomer  {Ztsclir.  f. 
Gcbiirtsh.  n.  Gyndh:,  xlvi.,  306,  1901)  gives  iodide  of  potassium  and 
iron  for  the  same  purpose. 

Treatment  of  Foetal  Nervous  Maladies, 

There  is  some  small  amount  of  evidence  to  show  that  phosphorus 
given  to  the  mother  in  pregnancy  may  have  a  beneficial  effect  upon 
the  fui'tus.  Nourse  and  W.  Fleming  Phillips  {Brit.  Med.  Journ.,  i.  for 
1899,  p.  1062)  have  written  on  this  subject.  The  latter  records  the 
case  of  Mrs.  L.,  who  had  had  six  children,  one  of  whom  was  idiotic, 
three  were  rickety,  and  the  youngest  died  of  hydrocephalus  within 
a  year  of  birth.  In  the  next  pregnancy,  Phillips  gave  a  mixture 
containing  2  grs.  of  calcium  hypophosphite  and  4  grs.  of  sodium 
hypophosphite  for  a  dose  during  six  months  ;  the  child  was  healthy. 
Two  years  later  the  same  treatment  was  followed  in  another  gestation, 
and  again  the  infant  was  healthy.  The  general  hygiene  of  preg- 
nancy was  also  attended  to ;  but  Phillips  gives  most  of  the  credit 


480  ANI'I'.NA'I'AI.    I'AIIIOI.OCY    AM)    I  I'l  ( 11 1'.XI'. 

to  the  medicine.  Of  course,  in  this  as  in  all  antenatal  treatment, 
one  is  conijielled  til  judjie  hy  consequences,  or  rather  hy  ]ihenomena 
wliich  may  or  may  not  be  consequences.  This,  however,  is  a  limita- 
tion inseparalile  from  tlie  siiliject :  it  a]>]ilies  niarkeilly  to  the  treat- 
ment of  ha'nio]ihilia,  of  wiiich  I  must  now  sjieak. 

Antenatal  Treatment  of  Haemophilia. 

As  has  been  said,  it  is  tlitlieult  to  judge  of  tlie  effects  of  antenatal 
treatment  because  of  the  absence  of  means  of  accurate  antenatal 
diagnosis.  The  cases  in  wliich,  therefore,  such  treatment  can  be 
tested  are  few  and  far  between.  The  well-known  tendency  of 
morbid  fcetal  states  to  repeat  tliemselves  more  than  once  in  the 
reproductive  history  of  the  same  mother,  gives,  however,  a  possible 
opi)ortunity  of  trying  to  influence  beneficially  the  healtli  of  the 
unborn  infant :  further,  the  hereditary  character  of  some  of  the 
maladies  wliich  thus  tend  to  repeat  themselves,  increases  the  ])ro- 
bability  of  the  antenatal  diagnosis,  although  it  must  be  confessed 
that  it  diminishes,  or  appears  to  diminish,  tlie  cliances  of  successful 
therapeutics.  Hiemophilia  is  a  malady  which  fulfils  the  conditions 
which  have  been  stated  above :  it  is  very  clearly  and  persistently 
hereditary,  and  it  also  shows  family  prevalence.  As  a  test  case,  then, 
it  has  advantages :  given  a  woman  who  comes  of  a  ha?mophilic  stock, 
who  has  a  hemophilic  father  or  ha?mophilic  brothers,  there  is  a  pro- 
bability that  her  male  offspring  will  be  h;emophilic ;  and  the  pro- 
bability is  greatly  increased  if  she  have  already  given  birth  to  one  or 
more  hemophilic  male  children.  There  is  a  presumptive  diagnosis, 
then,  of  antenatal  htemophilia  when  such  a  woman  is  pregnant  of 
a  male  infant.  But  as  a  test  case  it  has  also  disadvantages ;  hemo- 
philia is  a  very  intractable  disease,  and  it  may  be  urged  that,  if  it 
cannot  be  cured  after  birth,  there  can  be  little  hope  of  curing  it 
before  birth.  The  latter  statement,  however,  is  merely  an  opinion ; 
it  may  also  be  urged  that  it  may  be  easier  to  affect  beneficially  a 
morbid  state  before  birth,  i.e.,  in  the  foetus,  than  after  birth  ;  but  of 
this  more  anon.  Let  me  now  narrate  the  history  of  the  following 
case,  which  was  published  by  W.  X.  B.  Brook  (Lincoln)  in  the  Uritish 
Medical  Journal  (i.  for  1901,  p.  957),  and  by  myself  (126«).  On 
June  25,  1900,  I  received  from  Dr.  Brook  a  letter  in  which  he  stated 
the  facts  of  a  case  of  hemophilia  complicating  pregnancy  and 
laliour  which  he  had  in  his  practice  ;  and  he  closed  his  letter  with 
the  iiK^uiry,  whether  in  my  opinion  the  administration  of  chloride  of 
calcium  to  the  mother  in  pregnancy  would  prevent  the  child  from 
being  the  suliject  of  hemophilia.     The  case  was  as  follows : — 

Mrs.  C,  o4  years  of  age,  pregnant  for  the  third  time,  is  a  tall, 
well-built  woman,  ratlier  spare,  with  black  hair  and  a  sallow  com- 
plexion ;  she  has  always  lost  much  blood  at  her  menstrual  periods, 
and  had  post-partum  hemorrhage  after  both  confinements.  She 
last  menstruated  on  December  25,  1899,  and  expected  her  confine- 
ment in  October  1900.  Her  family  history  was  interesting :  her 
mother  w'as  healthy,  but  her  uncle  (mother's  brother)  died  at  the  age 


TREATMENT   OF   HAEMOPHILIA  481 

of  eleven  from  bleeding ;  she  herself  has  had  four  brothers  and  four 
sisters,  and  one  of  the  brothers  died  at  the  age  of  twelve  from 
bleeding ;  the  other  brothers  are  alive  and  healthy ;  the  four  sisters  are 
healthy,  and  their  male  children  are  also  healthy.  Her  first  preg- 
nancy ended  in  1891  in  the  birth  of  a  male  child;  there  was  a  con- 
siderable amount  of  hiemorrhage,  which  left  the  mother  weak ;  tlie 
child  at  birth  was  white  and  ana-mic ;  the  infant  survived  birth,  and 
is  still  alive,  but  is  a  marked  "  bleeder,"  and  bruises  easily,  and  has 
suffered  from  haemorrhages  into  the  joints  and  from  the  gums  during 
the  shedding  of  the  first  teeth.  In  fact,  he  nearly  succumbed  several 
times  from  great  bleeding  during  the  casting  of  the  milk  teeth.  The 
second  pregnancy  like^vise  ended  in  the  birth  of  a  male  infant  (in 
1894) :  there  was  again  j^ost-partum  haemorrhage  :  the  infant  showed 
haemorrhage  from  the  umbilical  cord  at  birth,  bruised  easily,  and 
died  at  the  age  of  twelve  months  during  dentition,  the  cause  of  death 
being  returned  as  cerebral  haemorrhage.  The  mother  is  now  pregnant 
for  the  third  time,  and  has  reached  the  sixth  month. 

Such  were  the  facts  upon  which  I  was  asked  to  form  an  opinion  as 
to  the  prospects  of  successful  antenatal  treatment.  I  replied  to  Dr. 
Brook  without  much  enthusiasm,  pointing  out  the  difficulty  of  being 
sure  that  the  fcetus  in  utero  was  hemophilic,  the  uncertainty  of  the 
sex  of  that  infant  even,  and  the  hereditary  nature  of  haemophilia. 
Hsemophilia,  I  remarked,  was  not  in  the  same  category  as  the  diseases 
such  as  syphilis  and  smallpox  and  typhoid  fever,  which  the  mother 
transmits  to  her  tVetus  in  utero ;  being  so  distinctly  and  persistently 
hereditary,  it  was  hardly  to  be  expected  that  antenatal  medication, 
begun  at  the  sixth  month  of  pregnancy,  would  greatly  aff'ect  it.  At 
the  same  time,  I  gave  it  as  my  opinion  that  chloride  of  calcimn  might 
safely  be  given  to  the  mother,  and  that  it  would  pass  through  the 
placenta  and  reach  the  foetal  tissues.  I  advised  that  the  treatment  with 
the  chloride  be  commenced,  although  theoretically  the  hopes  of  success 
were  small;  and  I  also  suggested  that  iron,  arsenic,  and  strychnin  be 
also  administered  in  order  to  improve  the  general  health,  and  jaos- 
sibly  to  increase  the  tone  of  the  uterine  musculature,  and  so  lessen 
the  risk  of  post-partum  hfemoi-rhage. 

Dr.  Brook  immediately  accepted  my  suggestions,  and  put  the 
patient  upon  a  mixture  containing  10  grs.  of  chloride  of  calcium 
thrice  daily;  this  was  continued  till  her  confinement  on  October  3, 
1900.  He  also  gave  her  a  pill  of  arseniate  of  iron  with  strychnin 
thrice  daily  till  September  17,  when  it  was  replaced  by  the  syrup  of 
the  phosphate  of  iron.  I  had  also  referred  to  the  possible  benefit 
that  might  follow  the  administration  of  thyroid  extract,  especially 
if  the  mother  did  not  show  the  normal  thyroid  hypertrophy  of 
pregnancy ;  but,  as  a  matter  of  fact,  thyroid  extract  was  not  given,  as  it 
was  difficult  to  say  whether  the  thyroid  gland  was  normal  in  size  or  not, 
and  it  was  thought  best  not  to  complicate  the  treatment.  During  three 
months,  therefore,  this  woman  received  the  above-mentioned  drugs. 

On  October  3,  1900,  the  confinement  took  place,  and  again  the 
child  was  a  male.  On  this  occasion,  however,  the  infant,  instead  of 
being  white  and  anremic  in  appearance,  was  red  and  mottled,  and  was, 


482  ANTKNATAI.    I'ATHOLOGY    AND    HYCilENE 

indeed,  in  all  respects  a  normal  cliild.  There  was  no  hremorrliage 
from  the  umbilical  cord  as  there  had  Ijcen  in  the  previous  case. 
Further,  for  the  first  time  in  the  mother's  obstetric  liistory,  there  was 
no  post-partum  hiumorrhage.  The  patient  was  able  to  nurse  lier 
infant,  but  Dr.  Brook  advised  that  this  sliould  not  be  attempted.  The 
labour  was  easy,  the  vertex  presented,  and  the  whole  process  did  not 
occupy  more  than  six  hours.  It  should  lie  added  that  the  cord  was 
not  tied  for  five  minutes  after  the  infant  was  Ijorn.  Since  October, 
Dr.  Brook  has  kept  me  acquainted  with  the  progress  of  the  case, 
which  has  been  quite  satisfactory  all  the  time.  The  infant  never  had 
any  bleeding,  and  did  not  bruise  like  his  brothers ;  during  dentition 
there  was  no  luemorrhage.  It  may  be  noted  as  of  some  interest  that 
his  eldest  brother  still  shows  the  bleeding  tendency  very  markedly ; 
during  February  he  had  severe  haanaturia,  which  was  uninfluenced 
by  turpentine,  but  rapidly  stopped  under  chloride  of  calcium  and 
thyroid  e.xtract. 

What  are  we  to  say  about  this  case  ?  Here  is  a  woman  with  a 
distinct  hereditary  history  of  htemophilia,  handed  down  to  her 
apparently  through  her  mother,  and  showing  itself  in  the  form  of 
post-partum  hemorrhage  and  profuse  menstruation,  and  in  the  pro- 
creation of  hiemophilic  male  infants ;  under  chloride  of  calcium,  and 
iron,  arsenic,  and  strychnin,  she  passes  through  her  third  pregnancy, 
is  confined  without  ])0st-partum  htemorrhage  of  a  male  infant  without 
hfemophilia !  The  treatment,  let  it  be  noted,  is  only  begun  at  the 
sixth  month  of  pregnancy.  Is  it  nothing  more  than  a  coincidence, 
a  remarkable  one,  no  doubt,  but  still  a  coincidence,  and  nothing  more  ? 
At  first  thought  we  are  inclined,  knowing  what  we  know  and  have 
been  taught  to  believe  regarding  the  intractable  nature  of  hereditary 
maladies,  to  accept  the  conclusion  that  it  was  a  coincidence.  If  we 
accept  the  other  view,  that  the  healthy,  non-h;emoiihilic  state  of  this 
woman's  third  son  was  due  to  chloride  of  calcium  administered  during 
the  third  trimester  of  pregnancy,  we  are  face  to  face  with  the  con- 
elusion  that  it  is  possible,  by  medicinal  substances  given  to  the 
mother  in  the  last  three  months  of  gestation,  to  cure  the  unborn 
infant  of  a  malady  which  no  medicines  in  after  life  are  capable  of 
curing.  Here  I  am  tempted  to  leave  the  question.  Certainly  it  is 
far  easier  to  take  it  that,  just  as  this  woman  had  four  brothers  only 
one  of  whom  was  a  bleeder,  so  of  her  three  sons  two  were  bleeders 
and  the  third  was  not  a  bleeder ;  even  with  the  most  hereditary  com- 
plaints some  members  of  a  family  escape.  It  was  merely  a  coincidence 
that  antenatal  treatment  was  instituted  in  the  case  in  which  the  heredi- 
tary influence  was  going  to  fail.  But  there  are  some  circumstances 
which  encourage  me  to  express  the  opinion  that,  after  all,  there  is  a 
chance  that  the  treatment  in  this  case  may  have  something  more  than 
a  coincidental  relation  to  the  healthy  state  of  the  third  infant. 

In  the  first  place,  it  may  be  taken  from  what  is  known  of  the 
physiology  of  the  fcetus,  and  more  particularly  of  jilacental  trans- 
mission, that  the  chloride  of  calcium  given  to  the  mother  reached 
the  fu'tal  tissues :  there  is  no  reason  to  doubt  that  the  iron,  arsenic, 
and  strychnin  did  so  also.    In  the  second  place,  there  is  evidence  that 


TRANSMISSION   OF   IMMUNITY  483 

chloride  of  calcium  is  beneficial  in  luumophilia  after  Ijirth,  and  there 
is  also  evidence  that  haemophilia  if  jjersistently  treated  in  postnatal 
life  shows  a  certain  amelioration.  In  tlie  third  place,  there  is  in  the 
extraordinary  power  of  recovery  possessed  by  the  fcetus,  a  factor  which 
nnist  not  be  left  out  of  account  in  dealing  with  all  questions  of  ante- 
natal treatment.  When  we  remember  the  marvellous  power  of 
growth  and  tissue-building  which  the  fcetus  displays,  a  power  so 
great  that  in  one  niontli  of  intrauterine  life  the  body-weight  is 
quadrupled,  we  are  led  to  ask  ourselves  whether  this  wonder  of  con- 
struction may  not  be  accompanied  by  an  equally  great  wonder  of 
reparative  energy  ?  If  there  be  a  greatly  exaggerated  %ns  medicatrix 
naturcc  in  the  fwtus,  is  it  not  possible  that  even  the  hereditary 
maladies  may,  if  properly  influenced,  show  a  tendency  to  cure  during 
antenatal  life  ?  May  it  not  be  that  medicines  acting  upon  the  organs 
and  tissues  while  these  are  still  in  the  stage  of  construction,  may  be 
more  efficacious  than  when  they  act  upon  structures  which  are,  as  it 
were,  sc(  either  for  health  or  disease  ? 

This  prolilem,  like  many  others  in  antenatal  pathology  and 
hygiene,  must  be  left  unsolved  ;  wo?i  liquef  must  again  be  the  verdict. 
Of  course,  we  cannot  be  too  careful  about  post  hoc  arguments ;  but 
unfortunately  they  are  all  that  we  have  to  trust  to  in  antenatal 
therapeutics,  and  that  they  are  untrustworthy  is  only  too  evident.  In 
this  connection  I  may  refer  to  the  carbonic  acid  bath  treatment  for 
the  prevention  of  monstrosities.  The  foreign  correspondent  of  the 
Medical  Times  and  Gazette  (vol.  i.  for  1861,  p.  209),  writing  from 
Driburg,  states  that  tlie  carbonic  acid  Ijaths  of  that  place  produced  a 
marvellous  ettect  upon  females  disposed  to  give  Ijirth  to  monsters. 
Dr.  Briick  had  under  his  care  a  lady  whose  general  health  was  ex- 
cellent, but  whose  first  pregnancy  had  ended  in  the  birth  of  a  micro- 
cephalus ;  she  took  the  baths  in  her  second  pregnancy,  and  had  a 
normal  infant:  in  her  third,  she  neglected  them  and  had  again  a 
microcephalus ;  in  her  fourth  pregnancy  tlie  baths  were  resumed,  and 
another  normal  infant  was  laorn  ;  in  her  fifth  pregnancy,  it  is  said  that, 
"  incredible  though  it  may  seem,"  she  again  neglected  the  baths  and 
had  another  microcephalus ;  but,  finally,  in  her  sixth  gestation  she 
returned  to  Driburg  and  had  another  normal  child.  Here  we  have 
the  post  hoc  argument  in  its  most  specious  and  convincing  form,  and 
yet,  I  fancy,  few  of  my  readers  will  feel  convinced. 

Transmission  of  Immunity  to  the  Foetus. 

Just  as  diseases  and  drugs  may  be  transmitted  to  the  fcetus  in 
utero,  so,  it  may  be  concluded,  may  innnuuities.  At  any  rate,  some 
evidence  of  this  passage  of  immunising  materials  has  been  found  in 
the  vaccination  of  pregnant  women  {ciilc  p.  194).  The  subject  need 
not  be  returned  to  here.  It  is  a  most  complicated  one,  but  it  is  a 
matter  in  which  progress  of  a  real  kind  may  yet  be  reported.  It  is 
conceivable  that  either  there  may  be  a  transmission  to  the  foetus  of 
the  antitoxin  prepared  in  the  mother's  body,  or  that  there  may  be  a 
transmission  to  the  fcetal  tissues  of  the  property  of  manufacturing 


484  ANTKNA'l'AI.    I'ATIIOLOGY    AND    IIYGIEN'E 

the  antitoxin.  0]\  tliis  and  allied  questions,  the  works  of  Ehrlicli 
{Ztsrhr.  f.  llijij.  u.  Jiifaiionti-Kranlcli.,  xii.  183,  1892),  of  Charrin  and 
Gley  {Arch,  cle  plij/siol.  norm,  et  'path.,  5  s.,  viii.  225,  1896),  and  of 
many  others,  may  be  consulted. 

Tn  yet  other  directions  tliere  may  be  expansions  of  tlie  tlierapeuties 
of  the  fu'tus  in  utero.  We  do  not,  for  instance,  know  whether  in 
cases  of  morbiparous  mothers  the  administration  of  the  thymus  or  of 
the  thyroid  extract  would  produce  any  Ijeneficial  effects  upon  tiie 
oiTspring ;  but  there  is  evidence  that  the  thynms  is  a  very  imi)ortant 
organ  in  the  fa-tus,  just  as  the  thyroid  is  very  active  in  tlie  infant. 
Perhaps  the  tliymus  may  check  excess  of  growth  and  formation,  for 
it  has  been  found  to  lie  small  in  the  large  foetus,  as  in  15.  Wolifs 
case  (Ccntrlbl.  f.  Gynulc,  xxv.  ."181,  1901).  We  do  not  as  yet  know 
any  drugs,  unless  it  be  chlorate  of  potash,  wliich  have  a  special 
effect  (good  or  bad)  upon  the  placenta,  but  there  may  Ije  such. 
There  is,  however,  one  line  of  treatment  which  has  sometimes  been 
advocated  (I  refer  to  the  induction  of  premature  labour  at  the 
eighth  month  when  the  mother  is  suffering  from  some  infectious 
malady),  which  must  be  regarded  as  of  very  doubtful  utility ;  it  is 
very  uncertain  if  by  so  doing  one  diminishes  the  chances  of  the  fcctus 
being  infected  by  the  mother,  while  it  is  quite  certain  that  one 
increases  the  risks  of  the  infant  succumbing  to  that  or  some  other 
infection.  I  believe  that  a  foetus  suffering  from  a  disease  will 
recover  more  satisfactorily  in  the  uterus  than  out  of  it,  and  I  do  not 
regard  the  chances  of  the  mother  as  lessened  l)y  the  presence  of 
such  a  fcetus  in  her  womb ;  but  even  if  her  chances  of  recovery  are 
slightly  less  good  on  that  accomit,  the  risks  of  a  premature  labour  will 
more  than  countervail. 

Germinal  Therapeutics. 

Therapeutics  in  the  earliest  period  of  antenatal  life  (the  germinal), 
when  the  future  organism  is  represented  by  two  specialised  cells 
(sperm  and  ovum),  must  of  necessity  be  both  paternal  and  maternal, 
and  it  must  be  mainly  prejiaratory  and  selective.  With  its  considera- 
tion I  have  not  in  this  volume  to  do,  for  it  belongs  to  the  pathology 
and  hygiene  of  the  embryo  and  germ,  and  calls  for  special  dis- 
cussion along  with  monstrosities-  and  malformations  and  morbid 
heredities;  but  I  may  very  briefly  indicate  some  of  its  salient 
points. 

It  will  l3e  concerned,  in  the  first  place,  with  the  health  of  the 
parents  after  marriage,  but  before  impregnation  has  occurred,  or 
between  successive  pregnancies.  With  a  view  to  the  procreation  of 
healthy  infants,  it  will  be  pointed  out  that  diseases  m  the  parents 
ought  to  be  combated,  such  as  syphilis,  alcoholism,  and  tubercle  in 
the  father,  and  endometritis,  renal  mischief,  syphilis,  and  alcoholism 
in  the  mother.  In  the  case  of  habitual  abortion  or  of  recurrent 
monstriparity,  as  in  the  family  history  narrated  by  myself  some  time 
ago  (117),  it  may  be  wise  and  right  to  recommend  curettage  of  the 


II 


\ 


i 


GERMINAL  THERAPEUTICS  485 

uterus  prior  to  a  new  pregnancy ;  and  persistence  in  antisyphilitic 
remedies  in  the  intervals  between  successive  gestations  is,  of  course, 
dc  riji'cur. 

In  the  second  place,  it  will  have  to  do  with  marriage  and  with  the 
restriction  of  the  marriages  of  the  unfit,  and  there  can  be  no  doubt 
that  there  is  wide  room  for  action  along  such  lines.  At  the  same 
time,  I  think  that  all  attempts  to  regulate  marriage  by  law  in  the  way 
that  has  been  so  often  suggested,  of  having  a  sort  of  bureau  of  inspec- 
tion of  candidates  for  matrimony,  must  be  regarded  as  premature  at 
least,  if  not  founded  actually  on  a  wrong  principle.  At  present,  it 
must  be  confessed  that  public  opinion  judges  of  the  suitability  or  un- 
suitability  of  a  proposed  marriage  very  much  by  the  amount  of  money 
the  young  couple  will  have  to  live  upon.  It  would  be  better  if  a 
basis  of  health  were  to  take  the  place  of  a  basis  of  wealth  in  the 
public  mind.  The  young  contracting  parties  often  say  they  are 
marrying  for  love,  and  that  is  right  enough  so  long  as  the  love  is  of 
the  right  kind ;  but  with  them,  also,  it  is  to  be  feared  that  physical 
and  mental  and  moral  health  does  not  take  the  high  place  it  ought  to 
do  in  determining  the  union. 

It  has  l-ieeu  said  by  a  writer  iu  an  American  journal  (B.  0.  Flower, 
in  the  Arena),  that  "  if  100  young  men  and  women  in  this  land, 
realising  tlie  solemn  import  of  this  question,  enter  the  marriage 
relation  attracted  by  pure  love,  untainted  by  base  or  sordid  considera- 
tions, and  recognising  the  great  moral  responsibility  they  assume  to 
the  society  of  to-morrow,  no  less  than  the  sacred  obligation  they  owe 
to  the  unborn,  we  shovdd  have  from  these  true,  pure,  and  ideal  unions 
children  who  would,  I  believe,  inaugurate  an  ethical  reformation  that 
would  awaken  the  moral  energies  of  civilisation,  and  lead  to  a  higher 
and  truer  order  of  life."  Francis  Galton,  in  his  HiLxley  Memorial 
Lecture  (October  29,  1001),  lias  advocated  something  akin  to  this 
for  the  possible  "  improvement  of  the  human  breed,"  and  has  pro- 
posed a  system  of  dowries  to  make  possible  the  early  marriage  of 
girls  of  a  favoured  stock  as  regards  health  ;  but,  of  course,  there  are  big 
problems  in  the  way. 

All  this  may  be  brought  about  ultimately ;  but  in  the  meantime, 
and  before  it  can  be  hoped  that  it  may  lie  accomplished,  it  is  necessary 
that  a  healthy  public  opinion  on  what  constitutes  a  good  marriage  be 
built  up,  and  in  the  building  up  of  this  opinion  the  profession  is  ex- 
pected to  act  as  a  guide  and  leader.  What,  for  instance,  has  the 
profession  to  teach  the  public  on  the  question  of  marriages  of  con- 
sanguinity ?  This  matter  has  been  rendered  most  uncertain  by  the 
confusion  which  has  been  introduced  through  the  mixing  up  of  two 
very  different  states — namely,  the  marriage  of  near  kin  or  incest,  and 
marriage  of  consanguinity  or  of  cousins.  In  the  former  case  there 
can  be  no  doubt  of  the  eil'ects,  and  every  breeder  of  domestic  animals 
will  support  this  assertion ;  but  the  marriage  of  cousins  is  a  different 
matter.  It  has  been  stated  that  such  marriages  result  in  sterility, 
abortions,  congenital  deaf- dumbness,  idiocy,  retinitis  pigmentosa, 
albinism,  and  such  malformations  as  Polydactyly  and  ectrodactyly. 
Now,  it  does  not  seem  that  consanguinity  i2)so  facto — that  is,  without 


486  ANTKNATAL    I'ATllOLOCJV   AND   IIYCUENR 

the  existence  of  traces  of  pre-existing  degeneracy  in  tlie  contracting 
parties — increases  the  risk  of  these  diseases  and  anomalies.  Fere 
goes  furtlier,  and  says  that  in  good  families  it  is  to  be  sought  for, 
nut  avoided ;  but  tlie  medical  man  will  be  well  advised  if  lie  be  very 
careful  in  the  advice  that  lie  oilers. 

The  chief  point  in  all  this  matter  is  that  the  ])rofession  and  public 
should  reiuiiin  no  longer  thoughtless  about  it.  Donald  T.  Massou  has 
pointed  out  what  "  breedmg  our  manhood  from  the  shots"  has  led 
to  and  is  leading  to  (Caledonian  Mid.  Journ.,  October  1898) ;  and 
many  others  have  iidduced  evidence  of  the  heredity  of  degeneracy. 
Various  legislative  measures  have  been  brought  forward  in  the  United 
States  of  America  dealing  with  the  jjroblem  of  marriage  restriction 
and  regulation  {vide  C.  W.  Parker,  Journ.  Amcr.  Med.  Assoc,  xxxiv. 
521,  1900  ;  D.  R  Brower,  ibid.,  p.  52:! ;  A.  H.  Burr,  ihid.,  p.  524 ; 
and  A.  Lee  Moque,  ihid.,  p.  526);  but  I  maintain  that  the  lirst  thing 
to  be  accomplished  is  the  education  of  public  opinion  on  all  such 
matters  by  the  medical  profession. 

In  the  third  jilace,  germinal  therapeutics  will  have  to  face  the 
problems  of  morbid  heredity;  and  that  they  are  problems  of  the 
gravest  kind,  every  one  will  readily  and  sadly  admit.  Morbid  heredity 
in  these  days  stalks  spectre-like  through  the  laud.  It  is  heard  in  the 
pulpit,  it  is  much  discussed  in  current  periodical  literature,  it  is  found 
in  the  popular  novel,  and  it  looks  at  you  from  the  stage.  There  are 
some — they  constitute  the  minority,  I  think — w'ho  treat  this  matter 
lightly.  For  them  the  question  has  no  terrors ;  every  man  has  his 
chance. 

"  Years  roll'J  on  years  successive  glide, 
Since  lirst  llie  world  liegan, 
And  on  tlie  tide  of  time  still  floats, 
Secure,  the  bark  of  man." 

But  there  are  others,  and  their  number  is  great,  to  wlioin  nmrbid 
heredity  is  a  spectre  that  w'ill  not  be  laid.  They  see  it  in  evervlhing. 
An  unreasoning  terror  seizes  them. 

If,  however,  they  will  only  think,  they  who  are  so  fearful  of 
morbid  heredity  will  soon  begin  to  realise  that  the  most  hereditary 
thing  in  the  world  is  the  normal,  not  the  abnormal ;  that  health 
is  transmitted  as  well  as  disease  :  that  even  where  the  past  history 
of  the  family  is  bad,  the  clean  livers  have  handed  something  to  their 
children  that  is  better  than  what  was  handed  on  to  them. 

It  begins  to  be  evident  that  inherited  diseases  and  anomalies  are 
rather  signs  of  the  breaking  of  heredity  than  instances  of  the  per- 
sistence of  it.  The  tendencies  of  the  germ  plasm  are  towards  the 
formation  of  normal  structures  capable  of  performing  their  functions 
normally  ;  but  they  are  liable,  through  the  action  of  iiKU-bid  causes, 
to  dissolution,  lluch  of  the  harm  that  is  done  to  the  germ  in  one 
generation  may  be  undone  in  the  next:  there  is  a  constant  tendency 
of  the  germ  plasm  to  return  to  right  pliysiological  paths,  if  it  be 
permitted. 

But  now,  again,  the  terrors  of  the  only  half-laid  spectre  come  back. 
Of   what  account   is  it   to   the  iiidi\i(lual  that  the  breaking  of  the 


HEREDITY  487 

normal  heredity  of  health  is  only  temporary,  and  not  of  necessity 
permanent  ?  Think  of  the  appalling  loss  of  life  and  health  that  is 
going  on  everywhere  before  the  return  to  the  normal  {le  retour  a  1% 
nu'diocrite)  can  be  accomplished  ! 

"  Are  God  and  Xature  then  at  strife, 
That  Nature  lends  such  evil  dreams  ? 
So  careful  of  the  type  she  seems, 
So  careless  of  the  single  life." 

It  can  be  answered  that,  in  the  very  nature  of  the  thing,  antenatal 
pathology  and  antenatal  health  cannot  be  restricted  to  one  generation. 
We  must  take  a  wider  view  than  that  which  includes  the  individual 
alone.  It  may  be  better  for  the  family,  for  the  race,  that  the  indi- 
vidual suffer  and  die.  This,  however,  the  individual  never  can  tell. 
Still  must  he  trust,  now  with  a  l)lind  belief,  but  yet  with  a  real  hope. 
Never  can  he  say  the  possibilities  of  the  vis  medicatrix  naticrce,  of 
the  vis  medkatrix  licrcditafis,  are  ended.  Suicide  is  not  the  answer 
to  the  sad  riddle  of  inherited  pathology,  but  individual  cleanness  of 
life  and  a  trust  in  the  tendency  to  return  to  health,  which  is  also  (and 
much  more)  an  attribute  of  the  germ  plasm. 

But  it  is  asked :  Why  should  such  things  be,  what  is  the  meaning 
of  antenatal  death,  disease,  deformity  ? 

"  The  same  old  liaffling  questions  !  0  my  friend, 
I  cannot  answer  them.     In  vain  I  send 
My  soul  into  the  dark,  where  never  bvu'n 
The  lamps  of  science,  nor  the  natural  light 
Of  Reason's  sun  and  stars  !     I  cannot  learn 
Tiieir  great  and  solemn  meanings,  nor  discern 
The  awful  secrets  of  tlie  eyes  which  turn 
Evermore  on  us  through  the  day  and  night 
With  silent  challenge  and  a  dumb  demand, 
Proffering  the  riddles  of  the  dread  unknown, 
Like  the  calm  Sphinxes,  with  their  eyes  of  stone, 
Questioning  the  centuries  from  their  veils  of  sand  ! 
I  have  no  answer  for  myself  or  thee 
Save  that  I  learned  beside  my  mother's  knee  ; 
'AH  is  of  God  that  is,  and  is  to  be  ; 
And  God  is  good.'     Let  this  suffice  us  still, 
Resting  in  cliildlike  trust  upon  His  will 
Who  moves  to  His  great  ends  unthwarted  hv  the  ill." 


I 


I 


APPENDIX 


EEFEREXCE  LIST  OF  THE  AUTHOR'S  CONTRIBUTIONS  TO 
MEDICAL  LITERATURE  FROM  1883  TO  1901,  WHICH  ARE 
REFERRED  TO  UNDER  THEIR  NUMBERS  IN  THE  TEXT. 

A.  Published  Works. 

1.  All  Infroduction  to  the  Diseases  of  Infancy :  The  Anatomy,  Physiolorjij, 

and  Hi/ffiene  of  the  New-born  Infant.  Oliver  &  Boyd,  Edinburgli, 
1891.     Pp.  viii,  242.     Plate.s,  9  (4  coloured),  and  Illustrations,  15. 

2.  The  Diseases  and  Deformities  of  the  Foetus:  An  Attempt  towards  a 

System  of  Antenatal  Pathology.  Oliver  &  Boyd,  Edinburgh,  1892. 
Vol.  i.  pp.  xiv,  252.  Plates,  13.  Subjects  considered  in  this 
volume  are :  The  Study  of  Foetal  Pathology,  its  Scope,  Delayed 
Progress,  Difficulties,  etc.  (chaps,  i.,  ii.) ;  Historical  Sketch  of  the 
Diseases  of  the  Foetus  (chaps,  iii.-vii.) ;  Classification  of  Diseases 
of  the  Foetus  (chap,  viii.);  Oeneral  Characters  of  Foetal  Disease 
(chap,  ix.);  General  Dropsy  of  the  Foettis  (chaps,  x.-xiii.);  General 
Cystic  Elephantiasis  (chaps,  xiv.-xvii.) ;  General  Foetal  Obesity 
(chap,  xviii.) ;  Index  of  Authors  and  Index  of  Subjects. 

3.  Tlie  Structures  in  the  Mesosalpinx :  Their  Normal  and  Pathological 

Anatomy.  (Jointly  with  the  late  Dr.  J.  D.  Williams.)  Oliver  & 
Boyd,  Edinburgh,  1893.  Pp.  52.  Illustrations,  12.  Subjects 
considered  in  this  work  are :  Anatomy  and  Histology  of  the 
Fallopian  Tubes,  including  Hypertrophy,  Hydro-,  Pyo-,  and 
Hsemato-salpinx,  Malformations  and  Displacements,  Tubercle, 
Cancer,  and  Cysts ;  Anatomy  and  Histology  of  the  Organ  of 
Rosenmiiller  or  Parovarium ;  Homologues  of  the  ]\Iesonephric 
Relics  in  the  Mesosalpinx ;  Pathology  of  the  Organ  of  Rosenmiiller, 
including  Cysts  and  Cancer ;  and  Anatomy  and  Pathology  of  the 
Vessels  and  Cellular  Tissue  of  the  jMesosalpinx. 

4.  Tlie  Diseases  and  Deformities  of  the  Fwtus.     Oliver  &  Boyd,  Edinburgh, 

1895.  Vol.  ii.  pp.  xii,  264.  Illustrations,  8.  Subjects  con- 
sidered in  this  volume  are  :  Sclerema  Neonatorum  (chaps,  i.-iv.) ; 
Atrophy  of  the  Subcutaneous  Tissue,  Subcutaneous  Abscess  in  the 
Foetus,  Dermatolysis  (cliai).  v.) ;  Foetal  Ichthyosis  (chaps,  vi.-viii.) ; 
Congenital  Ichthyosis  Hystrix  (chap,  ix.) ;  Tylosis  Palmm  et 
Plantse,  etc.  (chap,  x.);  Foetal  Keratolysis  (chap,  xi.);  Keratolysis 
Neonatorum,  etc.  (chap,  xii.) ;  Congenital  Cutaneous  Affections  in 
General  (chap,  xiii.) ;  Addenda,  Index. 

5.  Teratogenesis :  An  Inquiry  into  the  Causes  of  Monstrosities :  History 

of  the  Theories  of  the  Past.  Oliver  &  Boyd,  Edinburgh,  1897. 
Pp.  iv,  62. 

489 


400  ANTENATAI,    I>ATII()L(){;Y   AND    HYGIENE 

/)'.  Articles  in  ENCYCLor.EDiAs  of  Medicine. 

6.  "  Malformations  of   the  Female  Generative  Organs,"  in   Allbutt   and 

I'layfair's  Sijsteiii  of  Gi/mrrulor/t/  hi/  mami  writers.  JIacmillan  & 
Co.,  London,  1896.'    Pp.  63-112.     Illustration.s  31-39. 

7.  "  Le.s  Maladies  du  Fostus,"  in  Granchcr,  Coinby,  and  Marfan'.s  Traiti: 

(Jes  mdlatiif's  <h  Venfance.  Masson  et  Cie,  Paris,  1898.  Vol.  v. 
pp.  191-215. 

8.  "  Congenital  Disorders  and  Diseases  of  tlie  New-born,"  in   Keating'.s 

Cijclopwilia  of  the  DiseaKcn  nf  Children,  Supplementary  volume, 
pp.  1-17.  Lippencott,  Philadelphia,  1899.  Subject.s  included 
are  :  Congenital  Anasarca,  Elephantiasis,  Ascite.s,  Fcetal  Peritonitis, 
Infectious  Fevers,  Endocarditis,  Tuberculosis,  Prolapsus  Uteri, 
Osteogenesis  Imperfecta,  and  Congenital  Teeth. 

9.  "Congenital  Skin  Diseases,"  in  Keatmg's  CyclopcEdia  of  the  Diseases 

of  Children.  Supplementarv  volume,  pp.  1113-1123.  Lippencott, 
Philadelphia,  1899. 

10.  "Cheek,  Fissure  of,''  in  Green's  J'Jnri/elojxi-dia  Medira,  vol.  ii.  p.  19S, 

Edinburgh,  1899. 

11.  "Curettage,  Uterine,"  in  Green's  Enajclopaeilia  Medica,  vol.  ii.  j).  411, 

Edinburgh,  1899. 

12.  "Anatomy  of  the  Female  Organs  of  Generation."     Green's  Ennjch- 

pirilia  Medica,  vol.  iv.  p.  127,  1900. 

13.  "  Arrested  Developments  of  the  Female  Organs  of  Generation."     Green's 

Encydopwdia  Medica,  vol.  iv.  p.  1.50,  1900. 

14.  "Hermaphroditism."     Green's  Encj/clopo'dia  Medica,  vol.  iv.  p.  490, 

1900. 

15.  "  ^laternal    Impressions."      Green's    Encycloptpdia    Medira,    vol.    vii. 

p.  344,  1901. 
15rt.   "  >Ialformations  of  Genital  Organs."     Tieed'n  Text-Boo/c  of  Gi/iiecology, 

1901. 
15b.  "Diseases  of  the  New-born  Infant."     Green's  Enct/clopcedia  Medica, 

vol.  viii.  p.  345,  1901. 

C.  ^Medical  .Iournal. 

16.  Teratologia:  A  Quarterly  Jnitriial  of  Antenatal  Patholo(iy.     Williams 

&  Norgate,  London  and  Etlinburgh,  1894-1895.  Vol.  i.  pp.  viii, 
238.     illustrations,  12.     Vol.  ii.  pp.  iv,  344.     Illustrations,  21. 

D.  Contributions  to  the  Medical  Journals. 
1.  Gynecological. 

1 7.  "  Cases  of  Clinical  and  Pathological  Interest  in  the  Buchanan  AVard 

under  Profe,ssor  Simpson."  Edinh.  Med.  Joiirn.,  xxx.  438,  1884  ; 
Trans.  Edinh.  Obst.  Sac,  ix.  173,  1884.  Illustrations,  4.  The 
cases  recorded  in  this  communication  were  (1)  one  of  ligation  of  the 
blood  supply  of  the  ovaries  for  dysmonorrhoea,  etc. ;  (2)  one  of 
removal  of  a  hsematosalpinx ;  (3)  one  of  epithelioma  of  the  cervi.x 
in  a  woman  26  years  of  age ;  and  (4)  one  of  recurrent  fibroid  of 
the  cervix. 

18.  "Labia  Minora  and  Hymen."     Ediidi.  Med.  Journ.,  xxxiv.  425,  1888; 

Trans.  Edinh.  Ohst.  Soc,  xiii.  179,  1888.     Illustrations,  5. 


^ 


APPENDIX  491 

19.  "Histology   ami   Pathology   of   tlie   Fiilli>iiiaii    Tubes."     (.Jointly  with 

Dr.  J.'  D.  AViLLiAJis.)  Brit.  Med.  Journ.,  i.  for  1891,  pp.  107,  168. 
Illustrations,  7. 

20.  "Influenza  in  relation  to  Gynecological,  Ob.stetric,  and  Pediatric  Cases." 

Edinh.  Med.  Journ.,  xxxix.  615,  1894;  Tram.  Edinb.  Ol/sf.  Soc, 
xix.  33,  1894. 

21.  "Uterine  Curettage:    History,   Indications,   and  Technique."     Edinh. 

Med.  Journ.,  xli.  787,  908,  1896 ;  Trans.  Edinb.  Obst.  Soc,  xxi. 
69,  1896. 

22.  "So-called  Epispadias  in  Woman,  Avith  an  Illustrative  Case."     Edinb. 

Hosjj.  Rep.,  iv.  249,  1896. 

23.  "Congenital  Prolapsus  Uteri,  with  two   Illustrative  Cases."     (Jointly 

with  Dr.  J.  Thomson.)  Jn/.  Journ.  Obst.,  xxxv.  161,  1897. 
Illustrations,  3. 

24.  "Bicycling  and  Gynecology."     Scott.  Med.  and  Surr/.  Journ.,  ii.  529, 

1898  ;  Med.  Press  and  Circ,  ii.  for  1898,  p.  54.   '  ^ 

25.  "The  Sequelfe,  Usual  and  Uniisual,  of  Ovariotomy."     Infernat.  Clin., 

8  s.,  iv.  266,  1899. 

26.  "The   Present   Position   of   the   Pessary   in   Gynecological    Practice." 

Scott.  Med.  and  Surg.  Journ.,  iv.  289,  1899;  Trans.  Edinh.  Obst. 
Soc,  xxiv.  53,  1899. 

27.  "Digest  of  Recent  Literature  on  Atresia  of  the  Vagina."     Scoff.  Med. 

and  Surg.  Journ.,  iv.  536,  1899. 

28.  "  The  Antenatal  Factor  in  Gynecology."     American  Med.  Quart.,  i.  215, 

1900;  Trans.  Amer.  Assoc.  Olist.  and,  Gijiiec,  xii.  337,  1900. 

2.   Obstetrical  {including  Aiitenatal  Pathology). 

29.  "  Sphygmographic  Tracings  in   Puerperal   Eclampsia."     Eifinfi.    Med. 

Journ.,  XXX.  1007,  1885;  Trans.  Edmb.  Obst.  Soc,  x.  56,  1885. 
Illustrations,  35. 

30.  "  Report  of  the  Royal  Maternity  and  Simpson  Memorial  Hospital  for 

the  Quarter  ending  31st  January  1885."  (Jointly  with  Dr.  T.  B. 
Darling.)  Edinh.  Med.  Journ.,  xxxi.  259,  1885;  Trans.  Edinb. 
Of>st.  Soc,  X.  174,  1885. 

31.  "Sphygmographic  Tracings  during  Labour."     Trans.  Edinh.  Obst.  Soc, 

xi.  104,  1886. 

32.  "  Sphygmographic  Tracings  in  Pregnancy,  Labour,  and  the  Puerperium." 

Brit.  Med.  Journ.,  ii!  for  1886,  p.  i094. 

33.  "Frozen  Sections  of  a  New-born  Child  with  General  Dropsy."     Trans. 

Edinb.  Obst.  Soc,  xii.  161,  1887. 

34.  "  Mitral  Stenosis  in  Labour  and  the  Puerperium,  with  Sphygmographic 

Tracings."  Edinb.  Med.  Journ.,  xxxiii.  796,  1888  ;  Trans.  Edinb. 
Obst.  Soc,  xiii.  16,  1888.     Illu.strations,  21. 

35.  "Sclerema  and  Gidema  Neonatorum."     Brit.  Med.  Journ.,  i.  for  1890, 

p.  403.     Illustrations. 

36.  "Intrauterine    Rickets."     Edinh.    Med.    Journ.,    xxxv.    1111,    1890'; 

Trans.  Edinb.  Obst.  Soc,  xv.  45,  1890.     Illustrations,  3. 

37.  "The  Head  of  the  Infant  at  Birth,  Part  I."     Edinb.    Med.   Journ., 

xxxvi.  97,  1891  ;  Trans.  Edinb.  Olmt.  Soc,  xv.  103,  1890.  Illus- 
trations, 7. 

38.  "The  Relations  of  the  Pelvic  Viscera  in  the  Infant."     Edinb.  Med. 

Journ.,  xxxvi.  313,  1891  ;  Trans.  Edinb.  Obst.  Soc,  xv.  168,  1890. 
Illustrations,  5. 


492  ANTENATAL    I'ATIIOLOCJY   AND    IIYCilENE 

39.  "The  Head  of  Ihc   Infant  at  Birth,  Part  II."     Edinb.  Met!.  Journ., 

xxxvi.  4-29,  1891  ;  Trans.  Edinh.  Ohst.  Soc,  xv.  235,  1890.     Illu.s- 
trations,  2. 

40.  "Maternal    Impressions."     Edinh.    Med.    Journ.,    xxxvi.    G24,    11^91; 

Trans.  Edinh.  Ohst.  Soc,  xvi.  7,  1891. 

41.  "  JltTniorrhage  during  Labour  due  to  Vascular  Anouialy  (if  tho   Jlcni- 

hranes."     Edinh.  Med.  Journ.,  xxxvi.  1000,  1891  ;   Trans.  Edinh. 
Ohsf.  Soc,  xvi.  9.5,  1891.     Illu.stration. 

42.  "Relations  of  the  Abdominal  Viscera  in   the   Infant."     Edinh.  Med. 

Journ.,  xxxvii.  45,   1891  ;  'Trans.  Edinh.  Med.-Chir.  Soc,  x.  140, 

1891.  Plates,  4. 

4.'5.   "  ,V  Portable  Infant- Weigher."     Edinh.  Med.  .Journ.,  xxxvii.  321,  1891  ; 
Trans.  Edinh.  Ohsf.  Soc,  xvi.  105,  1891.     Illustrations,  2. 

44.  "  Disease  in  Early  Infancy."     Jirif.  Med.  Journ.,  i.  for  1892,  p.  321. 

45.  "The  Investigation  of  EcEtal  Disease."     Edinh.  Med.  .Journ.,  x's.x.vii. 

812,  1892;  Trans.  Edinh.  Ohst.  Soc,  xvii.  53,  1892. 
40.  "Rupture  of  the  Spleen  in  a  New-born  Infant."     Arcli.  Pediai.,  ix. 
27.5,  1892. 

47.  "The   Spinal  Column   in  the  Infant."     Edinh.  Med.  Journ.,  xxxvii. 

913,  1892  ;  TraJis.  Edinh.  Med.-Chir.  Soc,  xi.  71,  1892.     Plate,  1. 

48.  "Series  of  Thirteen  Cases  of  Alleged  JMaternal  Impression."     Edinh. 

Med.  Journ.,  xxxvii.   102.5,   1892;  Trans.  Edinh.  Obsi.  Soc,  ^\n. 
99,  1892. 

49.  "  Clinical  Notes  of  Four  Cases,  and  De.scription  of  Two  Specimens  of 

General  Dropsy  of  the  Foetus."     Edinh.  Med.  Journ.,  xxxviii.  57, 
142,  1892  ;  Trans.  Edinh.  Ohsf.  Soc,  xvii.  133,  1892.     Plates,  3. 

50.  "  Sectional  Anatomy  of  an  Auencephalic  Foetus."     Journ.  Anat.  and 

IVii/sioL,  xxvi.   516,   1892;  7'rans.   Edinh.   Ohst.   Soc,  xvii.   228, 

1892.  Illustrations,  3. 

51.  "General  Dropsy  of  the  Foetus."     Edinh.  Med.  Journ.,  xxxviii.  147, 
224,  1892;  Trans.  Edinh.  Ohsf.  Soc,  xvii.  148,  1892. 

52.  "  General  Dropsy  in  the  Twin-Foetus."     Trans.  Edinh.  Ohsf.  Soc,  xvii. 

177,  1892. 

53.  "  Case-taking  Scheme  for  Foetal  Diseases  and  Deformities."    Edinh.  Med. 

Journ.,  xxxviii.  434, 1892  ;  Trans.  Edinh.  Ohsf.  Soc,  xvii.  202, 1892. 

54.  "  An  Infant  with  a  Bifid  Hand."     Edinh.  Med.  Journ.,  xxxviii.  623, 

1893;  Trans.  Edinh.  Ohsf.  Soc,  xviii.  1,  1893.     Illustration,  1. 

55.  "  Description  of  a  Foetus  Paracephalus  I)ii)us  Acardiacus."     Edinh.  Med. 

Journ.,  xxxviii.   830,    1893 ;  Trans.  Edinh.   Ohsf.  Soc,  xviii.  38, 

1893.  Plates,  2. 

56.  "Congenital  ^leasles,  with  Notes  of  a  Case."     Arch.  Pediaf.,  x.  301, 

1893. 

57.  "Paracephalus  Dipus  Gardiacus."     Edinh.  Med.  Journ.,  xxxviii.  1095, 

1893;  Trails.  Edinh.  Ohsf.  Soe.,  xviii.  94,  1893.     Illustrations,  2. 

58.  "Congenital  Ascites  with  Retention  of  Urine."     Edinh.  Hosp.  Rep., 

i.  012,  1893. 

59.  "  Case  of  Scarlet  Fever  in  Pregnancy,  with  Infection  of  the  Foetus." 

(Jointly  with  Dr.  D.  jMilligan.)     Edinh.  Med.  Journ.,  xxxix.  13, 
1893;  Trans.  Edinh.  Ohst.  Soc,  xviii.  177,  1893. 

60.  "Notes  on  Six  Cases  of  Polydactyly."     Arrli.  Pediaf.,  x.  573,  1893. 

61.  "Two  Further  Cases  of  General  Dropsy  of  the  Foetus."     Trans.  Edinh. 

Ohst.  Soc,  xviii.  215,  1893. 

62.  "  Paracephalus  Dipus  Acardiacus."     Edinh.  Med.  Journ.,  xxxix.  321, 

410,  1893;  Traw.s-.  Edinh.  Ohst.  Soc,  xviii.  201,  1893. 


Uo. 


APPENDIX 


493 


Piiraceplialus  jNIonopus,   iVpu.s,  ami  PseuJoacormus."     Trans.  Edinh. 

Ohst.  Soc,  xviii.  257,  1893.     Plate,  1. 
Two   Cases   of   General   Dropsy   of   the    New-born    Infant."     Arch. 

Pediat.,  xi.  137,  1894. 
The  Foetus  Amorphus."     Terafologia,  i.  1,  1894.     Plates,  3. 
Tlie  First  Monograph  on  Foetal  Disease."     Teratoloiiia,  i.  37,  1894. 

Plate,  1. 
Congenital  Ichthyosis."     Arcli.  Pediat.,  xi.  257,  408,  1894. 
Case  in  which  Premature  Labour  was  induced  for  Contracted  Pelvis." 

Edinh.  Med.  Journ.,  xl.  4-5,  1894;  Trans.  Edinh.    Obsf.   Soc,   xix. 

126,  1894. 
Case  of  Hypospadias  in  a  New-born  Infant."     Terafologia,  i.  9G,  1894. 
Teratological    Records    of    Chaldea."       Terafologia,    i.    127,     1894. 

Plate,  1. 
Paracephalus  Dipus  Cardiacus."     Terafologia,  i.  158,  1894.     Plate,  1. 
Description  of  an  Anidean  Foetus."     Trans.  Edinh.   Obsf.  Soc,  xix. 

41,  1894. 
The  Fcetus  Amorphus  Anideus."     Trans.  Edinb.  Obsf.  Soc,  xix.  Gl, 

1894. 
The  Foetus  Amorphus  ]MyIacephalus."     Trans.  Edinb.  Obsf.  Soc,  xix. 

73,  1894. 
Case  of  Preaiu-icular  or  Branchial  Appendage."     Terafologia,  ii.  14, 

1895.     Plate,  1. 
Preauricular  Appendages."     Terafologia,  ii.  18,  1895. 
Pathogenesis  of  Preauricular  Appendages."     Terafologia,  ii.  65,  1895. 
Iniencephaly."     Terafologia,  ii.  87,  1895.     Plates,  3. 
Diphallic  Terata."     (Jointly  with  Dr.  Scot  Skirving.)     Terafologia, 

ii.  92,  184,  255,  1895.     Plates,  2. 
Rigor   i\Iortis   in   the   Fcetus."     Terafologia,    ii.    96,    1895 ;    Trans. 

^Edinh.  Obsf.  Soc,  xx.  20,  1895. 
Note  on  the  Literature  of  the  Fretus  Amorphus  Anideus."     Terafo- 
logia, ii.  182,  1895. 
Dr.    Pallares'    Dicephalic    Fcetus."        Terafologia,    ii.    210,     1895. 

Plate,  1. 
Antenatal  Pathology  in  the  Hippocratic  Writings."     Trans.  Edinb. 

Ohst.  Soc,  XX.  51,  1895;  Terafologia,  ii.  275,  1895. 
The  Biddenden  Maids."     Trans.  Edinh.   Ohst.  Soc,  xx.  128,  1895; 

Terafologia,  ii.  268,  1895.     Plates,  2. 
Teratological   Types  —  Iniencephaly."      Terafologia,    ii.    287,    1895 

Plates,  2. 
Teratogenesis :  Supernatural  Causes  of  Monstrosities."     Edinh.  Med. 

Journ.,  xli.  593,  1896;  Trans.  Edinh.  Ohst.  Soc,  xxi.  12,  1896. 
Case  of  Tylosis  Palmje  et  Plantse."     (Jointly  with  the  late  Dr.  George 

Elder.)     Pediatrics,  i.  337,  1896.     Illustration,  1. 
Congenital  Teeth."     Edinh.  Med.   Journ.,   xli.    1025,    1896;  Trans. 

Edinh.  Ohst.  Soc,  xxi.  181,  1896.     Plate,  1. 
Recent  Advances  in  Antenatal  Pathology."     Pediatrics,  i.  455,  1896. 
Anomalies  in  the  Form  and  Position  of  all  the  Male  Genitals,"  etc. 

Brit.  Med.  .Journ.,  i.  for  1896,  p.  1392. 
Teratogenesis :    Physical   Causes   of   Monstrosities."      Edinh.    Med. 

Journ.,  xlii.  1,  1896;  Trans.  Edinh.  Ohst.  Soc,  xxi.  220,  1896. 
Report  on  Mr.  J.  Rutherford  j\Iorison's  Case  of  Congenital  Tumour 

on  the  Face  of  a  Child."     Edinh.  Med.  Journ.,  xlii.   132,  1896  ; 

Trans.  Edinb.  Ohst.  Soc,  xxi.  256,  1896.     Plates,  2. 


494  ANTENATAL    PATHOLOGY   AND   HYGIENE 

93.  "Note   on    Dr.    M.  Gunsbiirg'.s  Teratological  Ca-ses."      Edinh.    Med. 

Journ.,  xlii.  139,  1X96';  Trans.  Edinh.  Obsf.  Soc,  xxi.  252,  1896. 

94.  "Teratogciicsis :    Mental  Influence."     Edinh.   Med.  Jo?/;-?;.,  xlii.  240, 

307,  1.S96;  Trans.  Edinh.  Ubst.  Sor.,  xxi.  258,  1896. 

95.  "  Mana^'einent  of  Labour  complicated    by    Death  or   Di.sease  of  the 
Fcetu-s."     Iidmtat.  Clinics,  6  .«.,  iv.  262,  1897.     Plate,  1. 

6.  "The  Causation  of  Twin.**,  as  Illustrated  by  some  Clinical  Histories." 
Trans.  Edinh.  Ohst.  Soc,  xxii.  29,  1897. 

97.  "  Displacement  of  the  Kidnej'  in  Ob.stetric  Practice."     Internal.  Clinics, 

7  s.,  iii.  312,  1897. 

98.  "  Congenital  Growth  (iVcanthoma?)  of  the  Hairy  Scalp."     lirit.  .Journ. 

Dermal.,  ix.  421,  1897.     Illustrations,  2. 

99.  "Digest  of  Recent  Literature  on  Transjiosition  of  the  \'iscera."     Scoll. 

Med.  and  Surg.  Journ.,  i.  1020,  1897. 

100.  "Placenta  Proevia  :   its  Dangers  and  Treatment."     Inlernat.   Clinics, 

8  s.,  i.  48,  1898. 

101.  "Pathology  of  Antenatal  Life."      CJlasgow   Med.  Journ.,  xlix.  241, 

1898;  Arch.  Pediat,  xv.  434,  1898. 

102.  "Occurrence  of  a  Non-Allantoic  or  A^itelline  Placenta  in  the  Human 

Subject."      Scolt.  Med.  and   Surg.  Journ.,  ii.  296,    385,  1898  ; 
Trans.  Edinh.  Ohst.  Soc,  xxiii.  54,  1898.     Plates,  3. 

103.  "  Three  Additional  Cases  of  Congenital  Teeth."     Trans.  Edinh.  Ohst. 

Soc,  xxiii.  112,  1898. 

104.  "Antenatal  Therapeutics."     Brit.  Med.  Journ.,  i.  for  1899,  p.  889; 

Arch.  Pediat.,  xvi.  513,  1899. 

105.  "  Spontaneous    Dislocation    Outwards  of  the    Right    Knee  Joint    in 

an   Infant   Eleven    Months    Old."      Arch.    Pediat.,    xvi.    267, 
1899. 

106.  "Pathology  of  the  Foetus."     Scott.   Med.  and  Sur<j.  Journ.,  \\  112, 

1899. 

107.  "Sequel  to  the   Case  of    Spontaneous  Recurrent  DLslocation  of   the 

Knee  .loint."     Arch.  Pediat.,  xvi.  701,  1899. 

108.  "  Some    Antenatal   Aspects    of    Tuberculosis."       Polyclinic,    L    39, 

1899. 

109.  "The  Position  of   Antenatal  Pathology."      Arc],.  Pediat.,  xvi.  860, 

1899. 

110.  "The   Antenatal   and    Intranatal   Factors   in   Neonatal   Pathologj-." 

Journ.  Avier.  Med.  Assoc,  xxxiii.  1245,  1899. 

111.  "Pathology  of  the  Embrvo."     S<-ott.  Med.  and  Suri].  Journ.,  v.  481, 

1899.^ 

112.  "The  Term  '  i\loon-calf ' ;  a  Teratological  Note."     Brit.  Med.  Journ., 

i.  for  1900,  p.  780. 

113.  "  Heredity  in  Disease."     Scott.  Med.  and  Surg.  Journ..  vi.  310,  1900  ; 

Trans.  Med.-Chir.  Soc  Edinh.,  xix.   114,  1900. 

114.  "  Chronology  of  Antenatal  Life."     Scott.  Med.  and  Surg.  Joiirn.,  vi. 

416,  1899.     Plates,  2. 

115.  "  Pathologv  of  the  Germinal   Period  of   Antenatal    Life."      Edinh. 

Hosp.'Pep.,  vi.  36G,  1900. 

116.  "Case  of   Vulvar  Hrematoma."      Scott.  Med.  and  Surq.  Journ.,  vi. 

505,  1900. 

117.  "A    Problem    in    Antenatal    Pathology:    Recurrent    Monstriparity." 

Amer.  Journ.  Ohst.,  xli.  577,  1900.     Illustrations,  3. 

118.  "Antenatal  Diagnosis."     Brit.  Med.  Journ.,  i.  for    1900,  pp.  1458, 

1525. 


APPENDIX  495 

119.  "Two  Cases  of  Congenital  Diaphragmatic  Hernia."     Pln/siciaii  and 

Surgeon,  i.  891,  1900.     Illustrations,  2. 

120.  "Case  of  Eclamp.sia  at  the  Sixth  Montli   of  Pregnancy  treated  by 

Saline  Infusions  and  Veratrum  Viride."     Scott.  Med.  and  Surg. 
Journ.,  vii.  19,  1900. 

121.  "Therapeutics  of  the  Unborn   Infant.''     Internat.   Clinica,   10  s.,   ii. 

p.  9,  1900. 

122.  "Contributions  to  Antenatal  Pathology."     Physician  and  Surqeon,  i. 

988,  1900. 

123.  "State  of  the  Spinal  Cord  in  Congenital  Absence  of  a  Limb."     Intrr- 

^taie  Med.  Journ.,  vii.  367,  1900. 
12-1.   "Report  on  Specimen  of  Foetus  in  Foetu."     Brit.  Med.  Journ.,  ii.  for 

1900,  p.  1428. 

125.  "  Cleidotomy :  An  Operation  accessory  to    Craniotomy  or  Lasilysis." 

Scott.  Med.  and  Surg.  Journ.,  viii.  48,  1901. 

126.  "  A  Plea  for  a   Pro-jNIaternity  Hospital."     Brit.  Med.  Journ.,  i.  for 

1901,  p.  813. 

126a.  "The   Antenatal   Treatment  of   Haemophilia.     Journ.  Amer.  Med. 

Assoc,  xxxvii.  503,  1901. 
126i.  "Abortions."     Internat.  Clinics,  11  s.,  vol.  ii.  231,  1901. 
126c.  "A  Visit  to  the  Wards  of  the  Pro-Maternity  Hospital."      Amer. 

Journ.  Ohst.,  xliii.  593,  1901. 

3.  General  Medicine,  etc. 

127.  "  Health  Aspects  of  School  Life."     Lancet,  ii.  for  1890,  p.  909. 

128.  "  Common  Errors  in  tlie  Rearing  of  Children."     Edinh.  Health  Soc. 

Trans.,  xi.  83,  1891. 

129.  "Folk-Lore  Factor  in  Medicine."      Our  Students'  Mar/a::ine,  viii  119, 

1900. 

130.  "Life  and  Work  of  Miss  Elizabeth  Blackwell  (1849-1899)."     Med. 

Mag.,  n.s.  ix.  117,  1900. 

E.  Shorter  Contributions  to  the  JIedical  Journals. 

131.  "  Case  of  Peritonitis  in  the  New-born  Infant."     Trans.  Edinh.  Ohst. 

Soc.,  XV.  56,  1890. 

132.  "  Case' of  Antemortem  Clot  in  the  Heart  of  an  Infant."     Ihid.,  p.  57, 

1890. 

133.  "Note  on  Syphilitic  Liver  in  the  New-born  Infant."     Ihid.,  [i.   91, 

1890. 

134.  "Case  of  Uterus  Bicornis  Septus."     Ibid.,  p.  160,  1890. 

135.  "  Case  of  Foetus  with  Encephalocele."     Edinh.  Med.  Jojirti.,  xxxyi. 

759,  1891. 

136.  "Dermoid  Tumour  expelled  per  vaginam  in   Labour."     Edinh.  Med. 

Journ.,  xxxvii.  750,  1892. 

137.  "  Retarded  Development  of  Embryo."     Edinh.  Med.  Journ.,  xxxviii. 

84,  1893. 

138.  "Exomphalos   and  Anencephaly  of   Fcetus."      Edinh.   Med.  Journ., 

xxxviii.  85,  1893. 

139.  "Umbilical  Hernia  in  a  Foetus."     Edinh.  Med.  Jo?«7j.,  xxxviii.  85, 

1893. 

140.  "  Multiple  Deformities  in  a  Fcetus."     Edinh.  Med.  Jonrn.,  xxxviii.  86, 

1893. 


49G  ANTF.NATAI,    I'ATIIOLOCY    AM)    lIVdlKNT, 

141.  "Hernia   of    Umbilical    Cnnl    in    a    Fa'tiis."     Edinh.    Mc<l.    Jaurn., 

xxxviii.  87,  1S93. 

142.  "Fro/en  Section.s  of  Exomjilialic  and  Anencephalic  Ftt'lu.';."     Edinh. 

Med.  ,/ourn.,  xxxviii.  17G,  1893. 

143.  "A  Knotted  Umbilical  Cord."       Edinh.  Med.  Journ.,  xxxviii.    178, 

1893. 

144.  "  Yelamentous  Insertion  of  the  Umbilical  Cord."     Edinh.  Med.  Journ., 

xxxviii.  179,  1893. 

145.  "Cysts  on  tlio  Fcetal  Surfa('e  of   Placenta."     Edinh.   Med.   Juurn., 

xxxviii.  863,  1893. 

146.  "  Abortion  Sac  from  Case  of  Habitual  .Vlternating  Miscarriaj,'!'."    Edinh. 

Med.  Journ.,  xxxviii.  864,  1893. 

147.  "  Fcetus  with  Measles."     Edinh.  Med.  Journ.,  xxxviii.  865,  189."!. 

148.  "Foetus  with  General  Dropsy."     Edinh.  Med.  Journ.,  xxxviii.  866, 

1893. 

149.  "  Steam  Steriliser  for  Infant  Feedins,'."     Edinh.  Med.  Journ.,  ws.\m. 

1059,  1893. 

150.  "Hydrocephalic  Fffitus."     Edinh.  Med.  Journ.,  xxxviii.  1059,  1893. 

151.  "Frozen    Section   of   a   Macerated   Foetus."       Edinh.    Med.   Journ., 

xxxix.  174,  1894. 

152.  "Frozen  Sections  of  Still-burn  Infant."     Edinh.  Metl.  Journ.,  xxxix. 

174,  1894. 

153.  "Foetus  with  Retroflexion  and  Spina  Bifida."     Ei/inh.  Med.  Journ., 

xxxix.  175,  1894. 

154.  "  Iniencephalic  Foetus."     Edinh.  Med.  Journ.,  xx.xix.  176,  1894. 

155.  "  Tubo-ovarian  Cyst  and  Ovarian  Concretions."     Edinh.  Med.  Journ., 

xxxix.  176,  1894. 

156.  "  Anenceplialic   Fo;tus   with   Cervical  Spina  liifida."      Eilinh.  Med. 

Journ.,  x.xxix.  272,  1894. 

157.  "Further  Note  on  Infant  with  Bifid  Hand."     Edinh.  Med.  Journ., 

xxxi.x.  273,  1894. 

158.  "Case  of  Kxternal  Subpericranial  Cephalhematoma."     Arch.  Pediat., 

X.  848,  1893. 

159.  "  Foetus  Com pressus  seu  Papyraceus."      Edinh.  Med.  Journ.,  xxxix. 

749,  1894. 

160.  "Frozen  Sections  of  an  Anenceplialic  Foetus."     Edinh.  Med.  Journ., 

xxxix.  750,  1894. 
IGl.  "  A  Fcetus  with  General  Dropsy."     Edinh.  Med.  Journ.,  xxxix.  835, 

1894. 
162.  "  A  Foetus  with  Imperforate  Anus."    Edinh.  Med.  Journ.,  xxxix.  836, 

1894. 
IG3.   "An  Exencephalic  Foetus."    Edinh.  Med.  Journ.,  xxxix.  836,  1894. 

164.  "A   Pseudcncephalic  Foetus."       Edinb.    Med.    Journ.,    xxxix.    837, 

1894. 

165.  "An    Abortion    Sac  and  Arrested   Embryo."      Ediidi.   Mod.  Journ., 

xxxix.  838,  1894. 

166.  "Foetus  with  Exomphalos  and  Sacral  Meningocele."      Eiiinh.  Med. 

Journ.,  xxxix.  1041,  1894. 
1G7.   "Frozen    Sections  of  Pelvis  of   a   Female   ^lonkey."     Edinh.   Med. 
Journ.,  xxxix.  1041,  1894. 

168.  "Foetus  with   Caudal  Appendage."       Edinh.    Med.    Journ.,    xxxix. 

1042,  1894. 

169.  "Still-born   Infant  with  Intracranial  IIa?morrhages."      Edinh.  Med. 

Journ.,  xxxix.  1042,  1894. 


APPENDIX  497 

170.  "  Large  Placenta  from  a  Case  of  Hvdramnios."     Edinb.  Med.  Joitrn., 

xxxix.  1043,  1894. 

171.  "  Fcetus  with  Anencephalus  and  Cervical  Spina  Bifida."     Edinb.  Med. 

Jouim.,  xx.xix.  1043,  1894. 

172.  "  Monochorionic  or  Uniovular  Twins."     Edinb.  Med.  Joitrn.,  x\.  78, 

1895. 

173.  "Foetus  with  Goitre-like  Swelling  of  the  Neck."     Edinb.  Med.  Joiirn., 

xl.  78,  1895. 

174.  "Dead-born  Infant."     Edinb.  Med.  ,Jonrn.,x\.  78,  1895. 

175.  "  Foetus  with  Ketrotlexion  of  the  Spina  and  Anencephalj'."     Edinb. 

Med.  Jouni.,  xl.  658,  1895. 

1 76.  "  Case  of  Dilatation  of  the  Bladder  and  Ureters,  and  Hydronephrosis 

in  a  Still-born  Infant."     Edinb.  Med.  Journ.,  xl.  858,  1895. 

177.  "Balanic  Hypospadias  in  a  Child."     Teratologia,  ii.  119,  1895. 

178.  "Protracted    Gestation    and    Anencephalus."       Teraioloqin,    ii.    120, 

1895. 

179.  "  Foetu.s  with  Anencephaly,  Spina  Bifida,  Talipes  Calcaneu.s,  and  a 

Malformed  Thumb."    ~Edinb.  Med.  Journ.,  xl.  1029,  1895. 

180.  "  Twin  Foetus  showing  Mummification  and  Flattening."     Edinb.  Med. 

Journ.,  xl.  1121,  1895. 

181.  "  Anencephalic  Foetus  with  Double  Hare-lip."     Edinb.  Med.  Journ., 

xli.  263,  1896. 

182.  "Diseases  of  Infancy  and  Antenatal  Conditions."     Brit.  Med.  .Journ., 

ii.  for  1895,  p.  712. 

183.  "Dicephalio  Foetus."     Edinb.  Med.  Journ.,  xli.  760,  1896. 

184.  "  Congenital  Elephantiasis."     Edinb.  Med.  Journ.,  xli.  761,  1896. 

185.  "  Iniencephalic  Female  Foetus."     Edinb.  Med.  Journ.,  xli.  857,  1896. 

186.  "Placenta  with  Persistent  Umbilical  Vesicle."     Edinb.  Med.  Journ., 

xli.  858,  1896. 

187.  "Frozen   Sections   of   Congenital   Diaphragmatic   Hernia."      Edinb. 

Med.  Journ.,  xli.  1057,"  1896. 

188.  "Three  Anencephalic  Foetuses."      Edinb.    Med.    Journ.,    xli.    1058, 

1896. 

189.  "An  Anencephalic  Fcetus."     Edinb.  Med.  Journ.,  xlii.  70,  1897. 

190.  "A  Foetus  Papj^raceus  or  Compressus."      Edinb.  Med.  Journ.,  xlii. 

169,  1897. 

191.  "Photographs   of   Infant   with   True   Congenital    Prolapsus    Uteri." 

Trans.  Edinb.  Obsf.  Sac,  xxii.  23,  1897. 

192.  "An    Anencephalic   Foetus."      Trans.    Edinb.   Obsf.  Soc,    xxii.    72, 

1897. 

193.  "  Congenital  Fibroma  of  Scalp  of  Xew-born  Infant."     Trans.  Edinb. 

dbst.  Soc,  xxii.  73,  1897. 

194.  "  Photographs  of  Teratological  Specimens."     Trans.  Edinb.  Obsf.  Soc, 

xxii.  81,  1897. 
195    "  Foetus  with  Exomplialos,  Sacral  jMeningocele,  and  double  Genital 
Tubercle."     Trans.  Edinb.  Obst.  Soc,  xxiii.  36,  1898. 

196.  "  Fcetus  with  large  I^ncephalocele."     Trans.  Edinb.  Obsf.  Soc,  xxiii. 

37,  1898. 

197.  "Foetus  with  Ascites  and  Distended  Bladder."     Trans.  Edinb.  Obsf. 

Soc,  xxiii.  37,  1898. 

198.  "Placenta   with    Supernumerary   Lobe."       Trans.  Edinb.  Obst.  Soc, 

xxiii.  38,  1898. 

199.  "Placenta   with    Succenturiate    Lobe."       Trans.    Edinb.   Obsf.    Soc, 

xxiii.  38,  1898. 
32 


498  ANTENATAL    I'ATHOLOGY   AND   HYGIENE 

200.  "FcEtuswith  Retroflexion  and  Torsion  of  the  Spine."     Trans.  Kdinh. 

Obst.  Sor.,  x.xiii.  53,  1898. 

201.  "  Pliotograph  of   a  Teratological  Chick."     Trans.  Kilinh.  Ohst.  Soc, 

xxiii.  .53,  1898. 

202.  "  .tViieucephaly  with  Diaphragmatic   Hernia."       Tratts.  Edinh.  Ohst. 

Soc,  xxii.  83,  1898. 

203.  "  Case  of  Fcetal  Bone  Disease."      Tra?is.  Edinh.  Ohst.  Soc,  xxiii.  84, 

1898. 

204.  "  Photographs  of  a  Limbless  Infant,"  etc.     Trans.  Edinh.  Ohst.  Soc, 

xxiii.  100,  1898. 

205.  "Frozen  Sections  of   a  Foetus  (anencephalic)  hardened  in   Fornml." 

Trans.  Edinh.  Ohst.  Soc,  xxiv.  16,  1899. 

206.  "  Large  IMultilocular  Ovarian  Cyst."      Trans.  Edinh.  Oh^t.  Soc,  xxiv. 

17,  1899. 

207.  "Large  Unilocular  Ovarian  Cyst."      Trans.  Edinh.   (ilisl.  Sor.,  xxiv. 

17,  1899. 

208.  "Vulvar  Epithelioma."     Trans.  Edinh.  Ohst.  Soc,  xxiv.  IS,  1S99. 

209.  "  Twin  Foetus  and  Placenta,  showing  the  First  Stage  of  Sympodia." 

Trans.  Edinh.  Ohst.  Soc,  xxiv.  18,  1899. 

210.  "  Secundines  from  three  Cases  of  Placenta  Pr.Tvia."     Trans.  Edinh. 

Obst.  Soc,  xxiv.  18,  1899. 

211.  "Cervical  Fibroid."     Trans.  Edinh.  0/jst.  Soc,  xxiv.  -16,  1899. 

212.  "  Siamese  Child  with  large  Congenital  Growth  on  the  Face."     Trans. 

Edinh.  Obst.  Soc,  xxiv.  47,  1899. 

213.  "Abortion  Sac."     Trans.  Edinh.  Ohst.  Soc,  xxiv.  47,  1899. 

214.  "  Secundines  from  a  Case  of  Central  Placenta  Praevia."     Trans.  Edinh. 

Ohst.  Soc,  xxiv.  48,  1899. 

215.  "Case  of  Missed   Abortion."      Trans.  Edinh.   Ohst.  Soc,   xxiv.   48, 

1899. 

216.  "Congenital  Hypertrophy  of   the  Hands   (Macrodactyly)."      Trans. 

Edinh.  Ohst.  Soc,  xxiv.  49,  1899. 

217.  "Boaistuau's    '  Histoires  Prodigieuses.' "      Trans.  Edinh.   Ohst.  Soc, 

xxiv.  49,  1899. 

218.  "  Frozen  Sections  and  Photographs  of  Iniencephalic  Foetus."     Trans. 

Edinh.  O'jst.  Soc,  xxiv.  79,  1899. 

219.  "  Frozen  Sections  and  Photographs  of  Anencephalic  Foetus."     Trans. 

Edin'j.  Obst.  Soc,  xxiv.  79,  1899. 

220.  "  Case  of  Anencephaly  and  Retroflexion  of  the  Spine."     I'rans.  Edinh. 

Ohst.  Soc,  xxiv.  80,  1899. 

221.  "Case  of  Foetal  Peritonitis."      Trans.  Edinh.  Ohst.  Soc,  xxiv.  123, 

1899. 

222.  "  Teratoma  from  Abdomen  of  an  Infant."     Trans.  Edinh.  Otji't.  Soc, 

XXV.  52,  1900. 

223.  "Foetus  with  absence  of  Radii  and  Deformity  of  Thumlis."     Trans. 

Edi?ih.  Ohst.  Soc,  xxv.  70,  1900. 

224.  "Anencephalic  Foetus."     Trans.  Edinh.  Ohst.  Soc,  xxv.  70,  1900. 

225.  "  Photographs  of  Historical  Teratological  Phenomena."     Trans.  Editd). 

Obst  Soc,xxv.  71,  1900. 

226.  "Foetal  Iniencephaly."     Tra7is.  Edinh.  Ohst.  Soc,  xxv.  144,  1900. 

227.  "Uromelic  Sympodial  Foetus."      Trans.  Edi>d>.  Obst.  Sor.,  xxv.  144, 

1900. 

228.  "Knot  on  the  Umbilical  Cord."     Trans.  Edinh.  Ohst.  Soc,  xxv.  144, 

1900. 


INDEX    OF   AUTHORS 


I 


Abel,  W.,  367. 

Achalme,  P.  J.,  60. 

Achard,  C,  200. 

Adaclii,  Buutaro,  105. 

Addinsell,  A.  W.,  407. 

Ahlfeld,  F.,  144,  268,  271,  305,  329, 

Allirecht,  K.,  198. 

Aldrovaiidus,  U.,  323. 

Allieri,  E.,  280. 

Allbutt,  C,  363. 

Andrews,  H.  R.,  386,  387. 

Anker,  M.,  263. 

Ansiaux,  G.,  265. 

Apert,  200,  348,  354,  407. 

Archambault,  P.,  303. 

Aristotle,  4. 

Arlidge,  J.  T.,  262. 

Armenteros,  F.  de,  254. 

Ashby,  H.,  379. 

Ashmead,  325. 

Aubinais,  P.,  203.  ' 

Auehe,  189,  208,  212,  213. 

Audebert,  230. 

Audion,  L.  P.,  61. 

Audion,  P.,  61,  65. 

Angagueur,  M.  V.,  328. 

Auspitz,  H.,  315. 

Aviragnet,  209. 

Bachimoxt,  168. 

Baer,  B.  F.,  421. 

Baerensprung,  F.  von,  225. 

Bailly,  M.  413. 

Baker,  B.,  262. 

Ballaiid,  J.,  260. 

Bar,   P.,  64,  144,  195,  209,  232,  234, 

236,  .327,  404. 
Barbezieux,  G.,  403. 
Barbour,  A.  H.  F.,  36,  37,  418. 
Birker,  Fordyce,  270. 
Barkow,  H.  C.  L.,  314. 
Barling,  G.,  340. 
Barlow,  T.,  353. 
Bartb,  372,  446. 
Bastianelli,  204. 
Batten,  F.  E.,  366,  367. 
Bauraes,  249. 

Baumgarten,  212,  213,  214. 
Bazin,  203. 
Beard,  J.,  142,  158. 


Beatty,  W.,  328. 

Beck,  G.,  473. 

BecK're,  195. 

Behm,  G.,  293. 

Behrend,  G.,  228,  307,  315. 

Eeigel,  H.,  323. 

Bellot,  372,  446. 

Benicke,  F.,  271. 

Bennewitz,  283. 

Beraud,  375. 

Bermann,  244. 

Bernhardt,  M.,  47. 

Besuard,  A.,  375. 

Betz,  F.,  375. 

Bidone,  E.,  138,  139,  140,  177,  183,  198, 

419,  441. 
Billig,  A.,  375. 
Birch-Hirscbfeld,  209.      • 
Biskamp,  A.,  348. 
Bissell,  J.  D.,  230. 
Blackwood,  C.  M.,  381,  382. 
Blau,  0.,  353. 
Blondel,  30. 
Blumcr,  G.,  328. 
Blmidell,  J.,  319. 
BIyth,  W.,  263,  264. 
Boeckh,  G.,  334. 
Bode,  E.,  353. 
Bohu,  203. 
Bond,  53. 

Bonnaire,  217,  407. 
Bonnet,  R.,  327. 
Booker,  86. 

Bordoni-Uffreduzzi,  G.,  221. 
Borntraeger,  J.  B.,  348. 
Borri,  L.,  265,  266. 
Bossi,  L.  M.,  419,  425. 
Boucliacourt,  170. 
Boucliacourt,  L. ,  470. 
Bouchard,  Oh.,  186. 
Bouchut,  203. 
Boulengier,  250. 
Bourgeoi.s,  L.  X.,  282. 
Bourneville,  164,  276,  305. 
Bovero,  155. 
Bowen,  J.  T.,  328. 
Boxall,  R.,  414. 
Braun,  C,  353. 
Braun,  E.  von,  329. 
Breslau,  267. 


500 


ANTENATAL    PATHOLOGY   AND    HYGIENE 


Brian,  163. 
Biiiidcau,  372. 
Brinoai,  H.,  383. 
Brook,  W.  N.  B.,  480. 
Bro.siu,  376. 
Brower,  D.  R.,  486. 
Brown,  E.  S.,  219. 
Browne,  Sir  T.,  429. 
Bruce,  357,  479. 
Briick,  483. 
Brim,  De,  397. 
Brunner,  C,  326. 
Brunzlow,  203. 
Bruyn  Kops,  C.  J.  de,  354. 
Budin,  P.,  447,  455. 
Bugge,  J.,  209. 
Bulkley,  L.  D.,  226. 
Buuge,  148. 
Burckhardt,  L.,  383. 
Bureau,  271,  203. 
Buret,  247. 
Burr,  A.  H.,  486. 
Butte,  L.,  159,  160,  279. 

Cacace,  E.,  337,  338. 

Caocini,  V.,  204. 

Cairns,  479. 

Cameron,  J.  C,  284. 

Campbell,  ^Y.,  329. 

Carbone,  T.,  310,  313,  314. 

Carbonelli,  G.,  221. 

Carita,  V.,  222,  223. 

Carrara,  M.,  273. 

Carriere,  G.,  216.' 

Carstanjen,  M.,  141. 

Carton,  A.,  353. 

Caruso,  F.,  297,  399. 

Caspary,  J.,  74,  315,  316,  317. 

Casper,  J.  L.,  178,  267,  413. 

Catliala,  376. 

Cathelineau,  H.,  264. 

Cattani,  198. 

Caulfield,  323. 

Cavazzani,  141. 

Caviglia,  P.,  419. 

Cestan,  R.,  348. 

Chamberlain,  W.  M.,  270. 

Chambevland,  C,  222. 

Chand:irelent,    200,    208,    212,    213,    283, 

354. 
Chantemesse,  A.,  199. 
Chantnniil,  190. 
('li:i|i.it-Prevost,  462. 
Charrrllay,  199. 
Cliaivot,  192,  351. 
Charpentier,  A.,  279. 
Charrier,  200,  320. 
Charrin,  149,  163,  182,  184,  195,  207,  212, 

283,  334,  484. 
Charrin,  A.,  201. 
Chatelain,  K.,  420. 
Chaussier,  394,  395. 
Cliiarleoni,  29. 
Chit'vitz,  J.    H.,   99,   106,   109,   110,   111, 

112,  114,  116. 
Chowne,  323,  413. 


Christopher,  372,  446. 
Cima,  1''.,  203,  235. 
Clark,  J.  G.,  425. 
Cless,  192. 
Coley,  W.  B.,  303. 
Colles,  225,  249,  250. 
Collina,  M.,  167. 
Condjemale,  274,  276. 
Comby,  J.,  55,  72. 
Corbin,  J.  E.,  201. 
Cordes,  L.,  308. 
Cordon,  320. 
Corin,  G.,  265. 
Courniont,  358. 
Coutts,  J.  A.,  250. 
Couvelaire,  382,  383. 
Couvelaire,  A.,  419. 
Crandall,  F.  M.,  203,  358. 
Crawford,  J.,  323. 
Crichton,  R.  W.,  375. 
Crocker,  Radclilie,  308,  318. 
Crooni,  J.  H.,  29. 
Curtze,  413. 
Cuthbert,  479. 

Dagincourt,  E.,  414. 

Dalziel,  219. 

Dana,  20. 

Dana,  C.  L.,  390. 

Daniel,  A.  S.,  308. 

Danyau,  375,  394. 

Date,  W.  H.,  318. 

d'Aulnay,  G.  R.,  230,  255. 

Daunie,  200. 

Davidson,  283. 

Davidson,  T.,  414. 

Decaisne,  272. 

Delamare,  283. 

Delestre,  M.,  221. 

Denielin,  72. 

Demme,  E.,  375,  376,  443. 

Depaul,  353 

Diday,  225. 

Diehl,  72. 

Diehl,  J.  C,  219,  220. 

Diener,  375. 

Dodd,  A.  H.,  326. 

Doehle,  244. 

Dogliotti,  A.,  200. 

Dohrn,  219,  220,  329,  414. 

Dolcris,  A.,  159,  160,  386. 

Dfillken,  103. 

Donath,  J.  F.  W.,  473. 

Doutrelepont,  244. 

Drappier,  275. 

Drennen,  250. 

Drummond,  W.  B.,  373. 

Dubrisay,  222. 

Duci,  14"4. 

Duclert.  182. 

Dark,  IL,  200. 

During,  E.  von,  250. 

Duttel,  P.  J.,  4,  188,  189. 

Dumeuil,  353. 

Duncan,  ,T.  Matthews,  184,  274,  283. 

Durante,  231,  354,  374. 


INDEX   OF   AUTHORS 


501 


I 


Durozier,  285. 
Duval,  D.  F.,  136. 
Duval,  M.,  1S6. 

Eberle,  0.,  235. 

Eberth,  C.  J.,  199,  353. 

Eckardt,  230. 

Euker,  A.,  323. 

Eden,  38. 

Edis,  A.  W.,  320. 

Edmunds,  W.,  166. 

Edwards,  32. 

Ehrlkdi,  484. 

Elder,  G.,  13S,  140,  141,  318,  438. 

Elliot,  G.  T.,  315. 

Englisch,  J.,  353. 

Engstrom,  E.,  28. 

Ercolani,  G.  B.,  230. 

Era.st,  P.,  199. 

Esmarch,  F.,  300. 

Etienne,  G.,  200,  201,  272. 

Everke,  C,  298. 

Fabkis,  F.,  380. 

Falk,  F.,  267. 

Fauvelle,  324. 

Fede,  F.,  337,  338. 

Feliling,  H.,  147,  268,  269,  271,  353. 

Feis,  0.,  414. 

Felkin,  AV.,  203. 

Feri',  Ch.,  20,  46,  170,  272,  274,  276,  435, 

486. 
Ferguson,  J.  H.,  223. 
Ferrari,  P.  L.,  181. 
Ferro,  R.  von,  353.  . 
Ferroni,  139,  140,  144,  169,  447. 
Fienus,  T.,  322. 
Fiexix,  279. 
Filipi)i,  A.,  353. 
Filomusi-Guelfi,  G.,  266. 
Finger,  244. 
Finizio,  170. 
Finkelstein,  62,  366. 
Finlay,  C,  198. 
Fischer,  A.,  347. 
Fischl,  R.,  228. 
Flechsig,  102,  103. 
Flemming,  C.  E.  S.,  354. 
Flensburg,  C,  162. 
Florschutz,  H.,  473. 
Flower,  B.  0.,  485. 
Foa,  P.,  221. 
Fordyce,  AV.,  200,  355,  356,  357,  358,  360, 

361. 
Fo'alis,  J.,  120. 
Fournier,  A.,  225,  247,  253,  254,  255,  257, 

478. 
Fournier,  E.,  240,  241,  243,  276,  478. 
Fo.x,  G.  H.,  318. 
Fox,  Tilbury,  328. 
Fraenkel,  200,  317. 
Fraenkel,  E.,  473. 
Frankel,  E.,  230. 
Franque,  0.  von,  353,  357,  424. 
Frascani,  V.,  199,  380. 
Frenkel,  200. 


Frerichs,  283. 
Freund,  200. 
Freund,  M.  B.,  267. 
Freund,  W.  A.,  29,  30. 
Frieker,  E.,  400. 
Friedlrinder,  S.,  265. 
Friedreich,  391. 
Friibelius,  375. 
Fuhr,  290,  296. 
Furst,  L.,  324. 
Fiirth,  225. 
Fussell,  M.  H.,  384-. 

G.^RTNER,  A.,  213. 

Gartner,  F.,  70. 

(iallavardin,  200. 

Galton,  F.,  485. 

Gauiayre,  262. 

Gardini,  138,  139,  140. 

Garrod,  A.  G.,  373. 

Gascard,  A.,  230. 

Gauthier,  G.,  164,  166. 

Genevet,  376, 

Gerard,  G.,  133. 

Gerhardt,  375. 

Gessner,  363. 

Geyl,  48,  324. 

Ghika,  C,  164. 

Gibb,  414. 

Giglio,  J.,  199,  446. 

Giles,  A.,  473. 

Gillespie,  A.  L.,  152. 

Gillette,  W.  R.,  270,  271. 

Glenn,  J.  H.,  219. 

Gley,  195,  334,  484. 

Gcickel,  C.  L.,  320. 

Goldberger,  H.,  329. 

Goldseheider,  A.,  328. 

Gradwohl,  R.  B.  H.,  218,  219. 

Graetzer,  173,  202. 

Grancher,  J.,  370. 

Grandidier,  65. 

Grandis,  V.,  149,  150. 

Gream,  G.  T.,  269. 

Gr^haut,  N.,  268. 

Griffith,  J.  P.  Crozer,  49,  200,  340. 

Grigg,  W.  C.,  413. 

Grinisdale,  T.  F.,  479. 

Grindon,  J.,  198. 

Grotthof,  F.,  354. 

Gubler,  A.,  232,  233. 

Gu<;niot,  353. 

Guillemet,  V.,  403. 

Guillemonat,  201. 

Guinard,  L. ,  163. 

GuUand,  G.  L.,  87,  142. 

Gusserow,  153,  163. 

Hahn,  C.,  455. 

Hall,  446. 

Hall,  J.  ST.,  372. 

Hallopeau,  315. 

Hallopeau,  H.,  328. 

Hanks,  H.  T.,  320. 

Hanot,  v.,  215,  216,  220,  443. 

Hansson,  386,  387. 


502 


ANTENATAL   PATHOLOCiY   AND    HYGIENE 


Harliitz,  F.,  354. 

Hardoiiiu,  362. 

Hart,  I).  B.,  397,  426. 

Harvey,  A.,  163. 

HusiH'ls,  J.,  473. 

Hans,  G.  A.,  307,  313. 

Hayiie,  L.  li.,  365. 

Hebra,  H.  von,  329. 

Hecker,  88,  89,  90,  91,  353. 

Hecker,  R.,  236. 

Hegele,  473. 

Heil,  K.,  386. 

Helme,  T.  A.,  102. 

Heniiig,  372,  440. 

Heniiig,  C,  230,  321. 

Henrotin,  F.,  27. 

Herrgott,  210. 

Herrgott,  A.,  354. 

Herman,  G.  K.,  285,  361. 

Hervey,  234. 

Hervieux,  E.,  230. 

Herzog,  27. 

Heubner,  225. 

Hildebrantlt,  199. 

Hildebrandt,  H.,  340. 

Hink,  W.,  353. 

Hippocrates,  4,  201. 

Hirst,  B.  C,  64,  221,  354,  472. 

His,  80. 

Hochsinger,  C,  225,  236,  244. 

Hochstetter,  329. 

Hochwelker,  H.,  163. 

Hoess,  F.,  348. 

Hoeven,  P.  C.  T.  van  der,  440. 

Hoffa,  50. 

Hoti'niann,  A.,  473. 

Hoffmann,  F.,  5. 

Hofmeyer,  268. 

Hijgyes,  A.,  268. 

Holmsen,  F.,  383. 

Hiinck,  E.,  293. 

Horn,  F.,  473. 

Houel,  307. 

Hourlier,  0.,  422. 

Hubreclit,  154. 

Hue,  E.,  192. 

Hudelo,  L.,  232,  233. 

Hueter,  G.  F.  G.,  320. 

Hugounenq,  L.,  142,  147,  148,  149. 

Huntingdon,  390. 

Husband,  A.,  283. 

Hutchinson,  J.,  7,  47,  225.  247,  250,  256, 

318,  327. 
Hutchison,  R.,  1.38,  140,  141. 

Ilott,  H.  J.,  424. 
Inglis,  A.,  479. 
Ireland,  W.  W.,  103. 
Ithen,  394. 

Jackson,  G.  T.,  323. 
Jaggard,  W.  W.,  407. 
Jahn,  J.  F.,  308,  313. 
Jakeseh,  "\V.,  294. 
Jamieson,  W.  A.,  318,  332. 
Janiszewski,  T.,  199. 


Jany,  C,  358. 
Jardine,  R.,  281. 
Jeannel,  397. 
Jell'cr.son,  32. 
■lenner,  E.,  193. 
Jennings,  D.  D.,  463. 
Jilden,  357. 
Joaeliimstlial,  G.,  326. 
Johannessen,  A.,  354. 
Jones,  B.,  414. 
Jones,  J.,  198. 
Jones,  J.  D.,  330. 
Jopson,  J.  H.,  301. 
Joseph,  M.,  328. 
Jo.sephson,  473. 
Jullien,  244. 
Jungbluth,  404. 
Justu.s,  235. 

Kader,  B.,  53,  54. 

Kaltenbaeh,  K.,  197. 

Kannegisera,  N.  S.,  414. 

Karvonen,  J.  J.,  2.36. 

Kassowitz,  225,  244. 

Katz,  164. 

Kaufmaun,  E.,   335,  336,   346,   348,    349, 

350. 
Keane,  A.  H.,  323. 
Keber,  266. 

Keiller,  A.,  307,  375,  479. 
Keim,  G.,  216. 
Ken-,  J.  Munro,  463. 
Kiderlen,  200,  217. 
Killiam,  71. 
Kircliberg,  A.,  353. 
Kirchberg,  J.  A.  A.  F.,  353. 
Kirstein,  E.,  285. 
Klebs,  285. 
Klein,  J.  H.,  353. 
Klem,  G.,  354. 
Knapp,  L.,  419. 
Knorr,  414. 
Koekel,  181,  209,  210. 
Kiilliker,  160. 
Koettnitz,  A.,  419. 
Korm.ann,  E.,  270. 
Kostial,  T.,  272. 
Krause,  L.,  386,  387. 
Krebs,  324. 
Kristeller,  380. 
Krukcnberg,  152. 
Kruska,  E.,  326. 
Kubassof,  P.,  271. 
Kuelienmeister,  F.,  425. 
Kuleukanipir,  D.,  300. 
Kiiss,  G.,  181,  209,  210. 
Kyber,  E.,  310,  311,  312,  313. 
Kynoch,  J.  A.  C,  400,  470. 


Lakoxt-Maerox,  H., 
Laniadrid,  J.  J.,  271. 
Lanibertz,  107,  120. 
Lanibinon,  H.,  419. 
Lanii)e,  R.,  354. 
Laneereaux,  276. 
Lang,  317. 


353. 


INDEX   OF   AUTHORS 


V 


UNIVERSITIY, 


OF 


Lange,  M.,  165,  2S1,  414. 
Langeudoi'ft',  160. 
Langerhans,  313. 
Langhans,  124,  125. 
Laimois,  163. 
Latis,  M.  R.,  223. 
La  Tone,  F.,  168. 
Laurens,  190,  191,  192. 
Lauro,  V.,  353. 
Laveran,  203. 
Lawrence,  J.  Z.,  323. 
Leale,  197. 
Lebedeff,  197. 
Lecard,  A.  J.,  353. 
Lecorche,  283. 
Lederer,  I.,  353. 
Lefour,  262,  382. 
Legrand,  H.,  260,  263. 
Legros,  190. 
Legiy,  222. 
Lehmann,  181. 
Lenipereur,  A.,  422,  423. 
Lepidi,  203. 
Leroux,  203. 
Leter,  L.,  276. 
LetuUe,  158. 
Leusser,  473. 
Levaditi,  149,  201,  282. 
Levi,  141. 
Levy,  200. 
Levy,  E.,  221. 
Liebreich,  F.  K.,  314. 
Liuck,  P.,  394,  395,  407. 
Lincoln,  262. 
Lindfors,  A.  0.,  298. 
Lisi,  223. 
Lisle,  J.  de,  244. 
Little,  389,  390,  391. 
Livingstone,  B.,  313. 
Lize,  A.,  263. 
Lobsteiu,  145. 
Luhlein,  H.,  29,  375. 
Loeffler,  211. 
Lombroso,  C,  323. 
Lomer,  R.,  479. 
Londe,  209. 
Lop,  195,  419. 
Lorain,  P.,  59,  60. 
Lorenz,  50,  51. 
Lovett,  R.  W.,  51. 
Lucas,  J.  C,  198. 
Luce,  J.  B.,  326. 
Ludwig,  H.,  152,  223. 
Lusk,  AV.  T.,  271. 
L'lstgarten,  244. 
Luzet,  Ch.,  220. 
Lynn,  189. 

M.VCDOFGALL,  J.  A.,  440. 
Mace,  231. 

Macvie,  S.,  282,  457. 
Magitot,  E.,  323,  325. 
Mainzer,  M.,  303,  304. 
Mairet,  274. 
Makins,  G.  H.,  354. 
Malgaigne,  375. 


Mall,  86.  ^^ —      ^^-^ 

Maniurotfski,  198. 

Mamby,  A.  R.,  320. 

Mansfeld,  353. 

Marchand,  F.,  222,  353. 

Margarucci,  0.,  354. 

Margouliefi',  192,  205. 

Marquis,  E.,  271. 

Martel,  285. 

Martin,  A.,  413. 

Martin,  E.,  35S. 

Mason,  R.  0.,  340. 

Massa,  C,  223. 

Masson,  D.  T.,  486. 

Mathewson,  G.,  239. 

Mattlies,  V.  AV.,  329. 

Mattison,  J.  B.,  270. 

Mauriceau,  F.,  355. 

Mayer,  L.,  375. 

Maygrier,  C,  456,  471. 

Meckel,  A.,  298,  299. 

Mejan,  T.,  192. 

Mekerttsciiiantz,  407. 

Melischer,  L.,  268. 

Mercelis,  71. 

Merkel,  F.,  99,  114. 

Mermann,  144. 

Metteuheimer,  H.,  99,  107,  113. 

Meurer,  473. 

Michelson,  315. 

Michelson,  P.,  324. 

Miklucho-Maclaj',  N.,  327. 

Milligan,  D.,  196. 

Milroy,  301. 

Milton,  410. 

Minot,  C.  S.,  55,  80,  85,  87,  120,  121. 

Mirto,  D.,  264. 

Miura,  I.  M.,  265. 

Moir,  J.,  479. 

Molenes,  P.  de,  326. 

Moncorvo,   174,   198,  203,   301,  303,  304, 

441. 
Moore,  B.,  161. 
Sloque,  A.  L.,  486. 
Moreau,  362. 
Mori,  E.,  353. 
Morisani,  D.,  222. 
Morrow,  P.  A.,  304. 
Mosse,  A.,  200,  376. 
Mott,  F.  W.,  92. 
Moussous,  370. 
MraJek,  F.,  228. 
Mueller,  A.,  380. 
Mueller,  H.,  353. 
Mtiller,  A.,  353. 
Midler,  L.  W.,  414. 
Midler,  S.,  336. 
Mtiller,  W.,  375. 
Muude,  P.  F.,  270. 
Munnicli,  A.  J.,  315. 

Nachtigallkr,  289. 
Nattan-Larrier,  158,  201. 
Nazaroff,  446. 
Neelsen,  F.,  298. 
Negri,  417,  445. 


504 


ANTENATAL    I'A'lllOI.OCY    AND    HYGIENE 


Neisser,  244. 

Nelson,  I).  T.,  267. 

Netter,  221. 

Ninigebaiier,  F.,  134,  135,  323,  386. 

Neuliaus,  2.'J0. 

Neuhaiiss,  R.,  199. 

Neumann,  G. ,  348. 

Newman,  283.  , 

Nicholson,  H.  0.,  137,  282. 

Nicloux,  M.,  140,  156,  273. 

Nissl,  103. 

Nonne,  M.,  301. 

Nutting,  J.  H.,  353. 

OESTllEllHElt,  307. 

Oiiilvii-,  (;.,  247. 

Oliuiann-Diimc-siiil,  314. 

Okel,  307. 

Ollive,  471. 

OUiviei-,  P.,  218. 

Olsliausen,  360,  361. 

Onoili,  169. 

Opitz,  E.,  134,  177,  3ri4,  383,  404. 

Orlotf,  425. 

Oime,  320. 

Osier,  W.,  201,  295,  30-3,  388. 

Paal,  H.,  353. 

Paci,  50. 

Padgett,  H.,  372,  446. 

Palazzi,  (i.,  218,  223,  26G,  267,  273, 

281,  362,  411. 
Palm,  H.,  194. 
Paris,  282. 
Parker,  C.  W.',   186. 
Parkinson,  C.  H.  W.,  413. 
Parreidt,  J.,  323. 
Parrot,  J.,  225,  238. 
Parry,  L.  A.,  326. 
Partridge,  E.  L.,  271. 
Paterson,  89. 
Paterson,  R.,  285. 
Paton,  D.  Noel,  473. 
Paul,  C,  260,  261,  262. 
Paullini,  C.  F.,  202. 
Peasl.-...,  270. 
Pe.liiini,  M.,  230. 
Peiser,  E.,  134. 
Pello,  P.,  354. 
Pennato,  P.,  204. 
Penrose,  32. 
Perez,  JI.,  315. 
Ferret,  447. 
Perrin,  E.  R.,  323. 
Perrondto,  E.,  222,  223. 
Peslalozza,  136,  137,  144,  169,  447. 
Petersen,  E.,  228. 
Petit,  219. 
Petit,  L.,  236. 
Pflui,',  375. 
l'liilil>e;uix,  267. 
Pliilli|.s,  \V.  v.,  479. 
Pi.iscrki,  272. 
Piekell,  324. 
Pii5ry,  194,  195. 
Piuard,  459,  471. 


Pinkuss,  354. 
Pitres,  354. 
Plaiicliu,  200. 
Playlair,  G.  R.,  203. 
Plottier,  A.,  264,  266,  271,  273. 
Poeoek,  F.  E.,  224. 
Pohlius,  322,  325. 
I   Pollmann,  285. 
Polosson,  376. 
Porak,  158,  180,  183,  260,  263,  264,  265, 

266,  267,  334,  340,  348,  354,   362,   383, 

463. 
Porta,  L.,  375. 
Pott,  R.,  293. 
Pradel,  272. 
Preiss,  E.,  473. 
Preuschen,  F.  von,  70. 
Preyer,   W.,   126,  143,  145,  146,  147,  163, 

170. 
Priestley,  ^^'.  0.,  328,  425. 
Proehowniek,  L. ,  473. 
Profeta,  247.  248. 
Pulewka,  265. 

QvEir.F.L,  217. 
Quinquaud,  268. 
Qvisling,  N.,  386. 

Radwansky,  386,  387,  388. 

Raineri,  G.,  295. 

Ranke,  ,T.,  323. 

Rapin,  463. 

Raynaud,  L.,  397. 

Recklinghausen,  1!.  von,  326. 

Regnanlt,  F.,  348. 

Reher,  H.,  199. 

Reid,  \V.  L.,  58,  283. 

Reillerscheid,  IC,  418. 

Reijenga,  J.,  473. 

Reinbaeh,  G.,  304. 

Remy,  S.,  386. 

Renon,  209. 

Rennert,  0.,  262,  263. 

Resinelli,  G.,  200,  363,  406. 

Restelli,  L.,  265. 

Reuhohi,  144. 

Reusing,  H.,  162. 

Ribhert,  H.,  379. 

Riliemont,  113. 

Riheniont-De.s.saignes,  A.,  320. 

Richer,  P.,  351. 

Richter,  307. 

Ricker,  G.,  217. 

Rieder,  390. 

Riehl,  0.,  257,  478. 

Kisohpler,  A.,  186. 

Hitter,  73,  319. 

Robinson,  0.,  100. 

Roger,  H.,  164. 

Rolleston,  H.  D.,  364,  365. 

Romano,  S  ,  222. 

Romberg,  M.,  353. 

Roque,  F.,  262. 

Rose,  304. 

Rosenblath,  W.,  222. 

Rosinski,  230. 


INDEX   OF   AUTHORS 


505 


Rossa,  E.,  161,  223,  420. 

Rostowzfw,  M.  J.,  222. 

Roth,  J.  H.,  354. 

Roiiget,  J.,  397. 

Royer,  C,  323. 

Ruge,  C,  230,  422. 

Rumpe,  R.,  348. 

Range,  M.,  «5,  66,  68,  69,  145. 

Russel,  P.,  202,  203. 

Saohse,  394. 

Saintu,  0.,  382. 

Salaghi,  M.,  354. 

Salisbury,  J.  H.,  244. 

Saliis,  449. 

Salvetti,  C,  354. 

Sanchez-Toledo,  213. 

Sangalli,  G. ,  222. 

Sanger,  284,  285,  294,  296,  414. 

Sanger,  W.  M.  H.,  353. 

Sarra,  R.,  304. 

Sarraute,  I.-G.  425. 

Sartorius,  0.  F.,  353. 

Sarwey,  216. 

Satullo,  S.,  399. 

Savory,  W.  S.,  163. 

Schaefer,  145,  224. 

Sehaeff'er,  0.,  386. 

Schaffer,  0.,  99,  110,  115. 

Schaller,  L.,  162. 

Scharfe,  H.,  133,  235. 

Snharlau,  353. 

Schatz,  ¥.,  163. 

Sehede,  M.,  326. 

Scheili,  354. 

Schenk,  375. 

Schiller,  H.,  407. 

Schlesint;er,  E.,  236. 

Sclilidlowsky,  E.,  353. 

Schloss,  0.,  303. 

Sehmey,  F. ,  354. 

Schmitt,  471. 

Schmorl,  181,  209,  210. 

Sclincider,  A.,  348. 

Schnitzlei-,  J.,  304. 

Scholz,  L.,  353. 

Selinider,  145. 

Sehuhl,  320. 

Selmltz,  386. 

Schultze,  413. 

Schultzc,  H.  S.,  329. 

Schulz,  G.  K.  A.,  353. 

Schiitz,  E.,  294. 

Schiitze,  70. 

Schwab,  230. 

Schwalbe,  99. 

Sehwarz,  F.,  337,  338. 

Schwarzwiiller,  G.,  353. 

Schwendener,  B.,  354. 

Schwyzer,  G.,  380. 

Seegen,  283. 
'        Seeger,  292. 
J        Sentex,  L.,  405,  422. 
I        Seulen,  290. 
I        Sevestre,  362. 
Seydel,  C,  265. 


Sfameni,  P.,  139,  141,  149,  150,  151. 

Shuttleworth,  462. 

Siebold,  C.  T.  von,  323. 

Siefart,  285,  294. 

Simon,  M.,  222. 

Simpson,  A.  R.,  3,  352,  375,  479. 

Simpson,  Sir  J.  Y.,  186,  236,  268,  307, 

362,  375,  479. 
Sireday,  262. 
Skene,  271. 

Skirving,  A.  A.  S.,  406. 
Smitli,  M.,  353. 
Smith,  Protheroe,  289. 
Smitli,  W.  R.,  313. 
Sonntag,  E.  H.,  347. 
Souty,  308. 
Spannochi,  T. ,  27. 
Sperling,  M.,  394,  395. 
Spiegelberg,  0.,  375. 
Spietschka,  T.,  303,  304. 
Sj)illmann,  L.,  348. 
Squire,  196. 
Squire,  Balmanno,  326. 
Stef,  H.,  264. 
Stcinbiiehel,  414. 
Steinthal,  303. 
Steinwirker,  H.,  298. 
St.  Florent,  V.  D.  de,  390,  391. 
Still,  G.  F.,  366. 
Stilling,  H.,  336,  340. 
Stoeltzner,  W.,  346. 
Stokes,  C.  E.,  401. 
Storp,  J.,  348. 
Strassmann,  407. 

Strassmann,  P.,  112,  133,  163,  264. 
Stratz,  197. 
Straube,  309. 
Strauch,  H.,  295. 
Straus,  I.,  222. 
Stricht,  0.  van  der,  142. 
Strieker,  W.,  323,  326. 
Stroebe,  236. 
Stumpf,  414. 

Sullivan,  W.  C.,  274,  275,  276. 
Sutton,  Bland,  307,  326,  344. 
Svehia,  K.,  164,  166,  167. 
Swan,  R.  L.,  394. 
Swiecicki,  von,  473. 
Symington,  J.,  336,  348,  349,  350. 

TAir,  Lawson,  293,  295. 
Tarnier,  455. 

TaruHi,  C,  353,  375,  377,  380. 
Taylor,  W.  T.,  203. 
Thiel,  230. 
Thiemich,  147. 
Thiercelin,  209. 
Thiry,  226. 
Thoma,  R.,  121. 
Thomas,  H.  M.,  48. 
Thompson,  J.  A.,  413. 
Thomsen,  391. 

Thomson,  A.,  87,  117,  118,  119. 
Thomson,  H.  A.,  336,  348,  349,  350. 
Thomson,  J.,  25,  347,  348,  353,  363,  365, 
367,  373,  384. 


506 


ANTENATAL   PATHOLOGY   AND   HYGIENE 


Thorburn,  J.,  479. 
Thoiner,  M.,  221. 
Thost,  318,  319. 
Thuriiam,  J.,  327. 
Tidy,  M.,  464. 
Tissier,  235. 
Tissot,  J.,  169,  414. 
Tizzoni,  198. 
Tschistowitsch,  T.,  354. 
Tomes,  C.  S.,  323. 
Toiirdes,  G.,  413. 
Tourette,  G.  de  la,  237. 
Town.send,  0.  W.,  340. 
Tridondaui,  E.,  417. 
Tripier,  L.,  353. 
Trousseau,  A.,  59,  60. 
Tnizzi,  E.,  358,  419. 
Tuke,  Hack,  462. 
Turner,  G.  A.,  58. 
Turner,  Sir  W.,  117. 

Unna,  p.  G.,  So,  318,  325. 
Uriel,  H.,  353. 

Valentin,  A.,  328. 

Vanoye,  244. 

Varaldo,  139,  142,  156,  204. 

Varnier,  448. 

Verneuil,  203. 

Viearelli,  G.,  146,  418,  419. 

Vierordt,  H.,  371. 

Villa,  F.,  348. 

Vinay,  Ch.,  283,  284,  285. 

Vircliow,  R.,  234,  292,  293,  295,  323,  353 

357. 
Vitanza,  R.,  198. 
Viti,  A.,  221. 
Vrolik,  G.,  308,  336,  340. 

Wagner,  234. 
Waitz,  303. 


Walker,  X.,  325. 

Wallic'Ii,  v.,  217,  230. 

AVarner,  ¥.,  315. 

Wassmuth,  A.,  307. 

Wasten,  134. 

Watelet,  315. 

Weber,  144. 

Weber,  F.,  376. 

Weber,  F.  P.,  372. 

Weber,  M.  J.,  353. 

Webster,  J.  C,  27,  425. 

Wegner,  G.,  237. 

Weir,  J.  J.,  323. 

Westphal,  W.,  380. 

Widal,  217. 

Widal,  F.,  199. 

William.s,  J.,  283. 

Williams,  J.  D.,  211. 

Williamson,  T.,  366. 

Wilson,  323. 

Winckel,  F.  von,  64,  65,  100,  283. 

Winfield,  J.  M.,  314. 

Winkler,  424. 

Winkler,  N.  F.,  347. 

Winslow,  K.,  203. 

Winter,  L.,  260,  263. 

Wolff,  B.,  484. 

Wurster,  146. 

Wyss,  353. 

Ygonin,  272. 
Young,  P.  A.,  413. 

Zaoaki,  G.,  223. 
Zalackas,  C.,  460. 
Ziingerle,  200. 
Zanier,  G.,  140. 
Zariquiey,  372. 
Ziegenspeek,  112. 
Zilles,  R.,  230. 
Zweifel,  P.,  26S,  269. 


INDEX  OF   SUBJECTS 


¥ 


Abdomen  of  Fcetus,  anatomy 
Abortion   .... 

etiology  of        . 

frequency  of     . 

in  fcetal  death  . 

in  neofcetal  period 
Absence  of  Skin,  congenital 
Acanthoma  of  Skin 
Accumulation  op  Microbes  and  Toxin; 
AcETONURiA,  in  pregnancy 
Achondroplasia  . 
Acromegaly,  cause  of 
Adaptive  Mechanism  at  Birth  . 
Adrenals  in  F(etal  Syphilis 
Age  -Incidence  of  Morbid  Processes 
Acglutinating  Principle  in  Fcetal  Ty 
Ainhum(?)  IN  the  Fffifus 
Albumoses  of  the  Liquor  Amnii 
Alcohol,  passage  from  mother  to  fretus 
Alcoholism,  effect  upon  the  fcetus 
Alimentary  Sy.stem,  diseases  of,  in  ftetus 
Allantoic  Placenta 

vessels  . 
Alopecia,  congenital 
Amnii,  liquor 

amount 

chemical  analysis 

functions 

in  fcetal  syphilis  . 

in  neofcetal  period 

meconium  in    . 

nutritive  properties 

renal  origin 

sugar    . 

temperature 

transmission  of  disease  througl 
Amnioma  of  Skin 
Amnion,  anatomy  of 
Amniotic  Adhesions  in  Fcetal  Fractuk 

in  fcetal  wounds 
Amniotic  Origin  of  Concenital  Ampu 

fractures 

wounds 
Amniotitis 
Amputations,  congenital  . 

spontaneous 


PAOE 

112 
425 
426 
455 
425 

84 
328 
330 
180 
418 
334,  347 
167 

38 
236 
5 
200 
397 
152 
273 
272 
355 
154 
121 
326 
125 
3,  89 
151 
153 
231 

83 
161 
153 
162 
223 
146 
182 
330 
125 
177 
178 
397 
394 
395 
405 
396 
178,  396 


508 


ANTENATAL    I'A'l'IlOLOCY    AND    HY(;iKNR 


rAOB 

Anatomy  of  Fcktus          ........        99 

of  ncofcctal  |ierioil 

80 

ANKNCEI'HALY  AXD  FlETAL  MOVEMENTS     . 

.       169 

Animals,  fcetal  iclithycsis  iu 

.       314 

fwtal  rickets  in             .             .             . 

.       S.-)! 

Annexa,  fcetal,  di.seases  of 

1 

75,  398 

Anteconcei'tionai,  Period  ok  Geuminai.  Like 

9 

Antenatal  Diagnosis 

.       431 

factor  in  gynecology    . 

.  22,  23 

in  neonatal  |iatliology. 

42 

fragility  of  liones 

48 

hygiene            .... 

405 

life,  divisions   .... 

6 

scheme              .... 

7,  10 

Antenatal  Patiiolii(!Y,  and  anatomy      . 

17 

and  general  |iathology 

17 

and  psychology 

•JO 

definition          .... 

i 

emergence         .... 

3 

interest  in        . 

12 

journal              .... 

13 

leetureshiii        .... 

13 

literature          .... 

3 

novelty             .... 

1 

practical  importanee     . 

2 

relations           .... 

16,  21 

subdivisions     .... 

12 

Antenatal  Pempuiuvs 

327 

prevention        .... 

14,  19 

therapeutics      .... 

ira,  4 

00,  465 

Anthrax,  fu-.tal     .... 

222 

Aouta  ok  FfETUs,  anatomy  of 

1 

11,  116 

"  Apoplexies  "  in  the  Placenta 

398 

Appendicular  Circulation  in  the  Foetus 

131 

Appendix  ..... 

489 

Appendix  Vkrmiformis  of  Fcetus,  anatomy  of 

115 

development  of             .             .             . 

90 

Arsenical  Poisoning  in  the  Fcetus 

266 

Arvthmic  Character  of  Fietal  Cardiac  Cycl 

E 

135 

Ascites,  tVetal        .... 

355 

in  syphilis 

237 

Asphyxia,  IVctal    . 

1 

63,  411 

neonatorum 

75 

"  Asterion"  Region  of  Skull 

104 

Asymmetry  of  F(ETAL  Head 

101 

Ataxia,  Friedreich's 

391 

Atheroma,  antenatal 

374 

Atrophic  State  of  SuiicuTANEOUS  Tissue 

305 

AUTO.MATIC  Character  of  Fietal  Cardiac  Action 

134 

Bacillus  of  Syphilis       .... 

244 

Bacteria,  transmi.ssion  through  the  placenta 

157 

Bacteriology  of  Fietal  Anthrax 

222 

erysipelas         .... 

197 

pneumonia        .... 

221 

sepsis   ..... 

217 

typlioid             ..... 

199 

Baumgarten's  Theory  of  Latency 

213 

BiDLIOGRAPHV  OK  ANTENATAL  KiGOR  MoRTIS 

413 

author's  works 

489 

congenital  goitre          .... 

375 

congenital  i>rolapsus  uti li 

386 

foetal  bone  disease         .... 

353 

obliteration  of  the  bile-ducts    . 

365 

Birth,  funi'tional  changes  at 

39 

readjustment  of  functions  at    . 

38,  39 

^uro^^^ 


INDEX   OF  SUBJECTS 

Birth — continued. 

separation — results  of  . 
traumatism  of . 

BiRTH-KATE,  fall  ill 

Bladder  of  Fcetus,  anatomy  of   . 

(listension  of    . 

hypertrophy  of 
BLENORRHffiA  NeON ATORFiM 

umbilici 
Blood,  development 
distriliution 
chemistry 
histology 
in  neofretal  period 
in  syphilis 

BOGEXFURCHE 

Bone  Diseases,  fretal 
Bones,  antenatal  fragility  of 

in  fcotal  syphilis 
Brain  of  F(etus,  anatomy  of 

changes  in,  in  neoffctal  period 

development  of 
Bronohooele,  intrauterine 
Bronzed  H.emath;  Disease 
Buccal  Cavity  of  Fcetus,  anatomy  of 

secretions  in  the  fcetus 
Buhl's  Disease     . 
Bunge's  Law 

C^CUM  OF  Fcetus,  anatomy  of 
Calcareous  Deposits  on  Placenta 
Cancer,  maternal,  state  of  fretus  in 
Caput  Succedaneum 
Carbonic  Oxide  Poisoning  in  the  Fietu; 
Cardiac  Action  in  the  Fcetus 

circulation  in  fcetus 

impulse,  jialpation  of  . 
Cardiogram  of  Fcetus 
Cephalhematoma  Neonatorum 
Cephalometer  in  Antenatal  Diacjnosis 
Cerebellum,  development  of 
Cervix  Uteri,  antenatal  laceration 
Chaldea,  teratological  records 

Chemical  Examination  of  Excretions  in  Antenatal 
Chemical  Substances,  transmission  through  the  iilacenti 
Chemistry  of  the  Fcetal  Liver 

urine    . 

of  the  fcetus 

liquor  amnii    . 

meconium 

placenta 

veruix  caseosa 
Chloroform,  influence  upon  the  fcetu 
Chlorosis  and  Malformation 
Cholera  in  the  Fcetus    . 

ChONDRODYSTROPHIA  FlETALIS 

Chorea,  congenital    . 
Chorion,  anatomy  of 

development  of 

in  neofretal  iieriod 

villi  of,  structure  of     . 
Circulation  in  the  Fcetus 

changes  in,  at  birth 

extra-corporeal 

intra-corporeal 
Circulatory  Changes  at  Birth 

system,  diseases  of 


88,  89 


509 

PAOK 

37,  38 

35 

13,  456 

116 

u79 

381 

52,  53 

62 

86 

131 

141 

139 

83 

235 

86,  87 

334 

48 

237 

101 

82 

91,  92 

374 

64 

103 

159 

63,  64,  65 

148,  448 


114 

151 

282 

36,  37 

267 

133 

129,  135 

136 

137 

44,  45 

447 

89 

32 

4 

448 

156,  157 

159 

162 

147 

151 

161 

150 

160 

268 

20 

198 

335,  347 

390 

125 


124 
127 
132 

127 
129 


510 


ANTENATAL   PATHOLOGY   AND   HYGIENE 


Classification  of  Fo-nAi,  Honk  Diseases 

morbid  states  . 

movements 
Clavicle  of  FtEius,  anatomy  of  . 

ossification  of  . 
Cleidotomv 
Clinical  History  of  Congenitai,  ELKriiANTiAsis 

bone  disease 

congenital  hyiiei-tiicliosis 

fcetal  ascites 

death    .... 

endocarditis 

general  ffctal  dropsy     . 

hydramnios      ... 

ichthyosis 

malaria 

measles 

obliteration  of  the  bile-iUu^ts    . 

variola 
Cloaca,  development  of     . 
Closure  of  the  Foramen  Ovale  and  D 
Clouding  of  Cornea,  congenital . 
Coal  Gas  Poisoning  in  the  F(etus 
CoLLEs' Law  IX  Svi'HiLis. 
"  Collodion  FfETUs  " 
Colon  of  Fcetus,  anatomy  of 

hypertrophy  of 
Comparative  Emuryologv 

fcetal  pathology 

histology  of  placenta    . 

teratology 
Complications  of  Fcetal  Variola 
Composition,  chemical,  of  fcetal  blood 
Congenital  Absence  of  Skin 

alopecia 

bullous  dermatitis 

cystic  elephantiasis 

elephantiasis    . 

goitre   .... 

hypertrichosis  . 

jiemphigus 

syphilis 

torticollis 
Conjunctivitis,  gonorrhccal,  of  new-born 
Convolutions  ok  the  Umbilical  Cord 
Copper,  poisoning  with,  in  pregnancy 
Cornea,  congenital  clouding  of     . 
Coronary  Sinus  of  Placenta 
Corpuscles,  red,  in  the  fcctus 

white,  in  the  fcctus 
Cranio-Pharyngeal  Canal  in  Fcetus 
Craniotabes 
Cranium  of  Fcetus,  anatomy  of  . 

development  of 
Cretin,  goitrous     . 
Cretinism,  congenital 
Cyanosis,  pernicious  icteric 
Cystic  Elephantiasis,  congenital 

Dasytes  .... 
Death  of  Extrauterine  F<etus 
Death  of  the  Fcetus 

pathology  of     . 
Decidual  Membranes,  anatomy  of 

development  of 

in  neofcetal  period 


INDEX  OF  SUBJECTS 


511 


Definition  of  Antenatal  Pathology 

con<»eiiit!il  elephantiasis 

congenital  goitre 

congenital  hyiiertrichosis 

congenital  obliteration  of  bile-duets 

f(_etal  ascites 

ftetal  ichthyosis 

fretal  keratolysis 

genera!  iietal  dropsy    . 

hydraninios 

tylosis  palmie   . 
Deformities,  embryonic  in  origin 
Decexekation,  fibro-fatty,  of  placenta 
Dehmatitis,  congenital  bidlou 

exfoliativa  neonatorum 
Dekmoids  in  the  Fietus  . 
Desquamation,  physiological,  in  new-lior 
Development  of  Fcetus  . 
Diabetes,  maternal,  state  of  fii.'tu; 
DlAl'.ETES  MeLLITUS  IN  F(ETUS 
Dia(;nosis,  antenatal 

of  fcx'tal  death  . 

fietal  endocarditis 

fetal  morbid  states 

general  f  efcil  dropsy     . 

hydramnios 

intranatal 

neonatal 

oliliteration  of  the  liile-ducts 

postnatal 
DiAriiKAGM  IN  FcETUS,  anatomy  of 

development  of 
Diet  in  Pregnancy 

of  mother  and  chemistry  of  fretus 
Difficulties  of  Antenatal  Diagnosis 
Digestion  in  the  Fcetus  . 
Dicestive  Changes  at  Birth 
Digits,  development  of 

DlTLOTERATOLOGT 

Diseases,  fecial 

and  malformations 

idiopathic 

of  the  fcetal  annexa 

skeleton 
Diseases,  transmission  of,  from  fcetus  to 

through  the  placenta    . 
Diseases,  transmitted 
Dislocations  in  the  Fcetus 

in  the  new-born  infant 

spontaneous  of  knee     . 
Divisions  of  Antenatal  Life 

jiathology 
Dropsy,  general,  of  the  fetus 
Ductus  Arteriosus,  anatomy  of 

closure  of,  at  birth 
Ductus  Thyreo-Glossus  . 
Duodenum  of  Fcetus,  anatomy  of 
Dy'strophies  of  Alcoholism 

of  fcetal  syphilis 

of  fcetal  tuberculosis     . 

Ear  of  Fcetus,  anatomy  of 

anteversion  of . 

develojiment  of 
Eclampsia,  maternal,  effect  on  Fi 

on  placenta 


PAGE 

2 

300 

374 

321 

363 

355 

306,  315 

319 

289 

400 

318 

185 

399 

327 

72 

174 

73 

92,  93 

283 

223 

431 

416 

372 

430 

296 

402 

449 

432 

365 

450 

108 

86 

472 

147 

430 

160 

40 

85 

12 

173,  188 

.        186 

175,  288 

175,  398 

.       334 

.       184 

156 

.       175 

.       395 

49 

.       214 

6 

12 

.       288 

111,  112 

.       133 

83 

.       114 

243,  276 

.       239 

214,  243 

.  104 
85 
.  84,  87 
.  278 
.       281 


512 


ANTENATAL    l>A  ril()I.()(;'>    AM)    HVCIKNK 


ECZKMA  NkONATORU.M 

Effects  of  F(etai.  SvriiiLis 
Elastic-  Fibrks  ix  Skin,  flevclo]>nieiit  of 
"  Elastic:  Skinnki)  Mf.x  " 
Elei'Haxtiasis,  cougeiiital 

cystic    .... 
EMnRYOLOOY,  comparative 
E.MllRYONIC  CONTRA.sTKll  WIIH  F(i;rAr,  Lu 

factor  in  fcftal  iiatliolupy 

]iatholoj;y  ... 

period  of  life     . 
Emergence  of  Antenatal  rATiioLocY 
Endarteritis,  in  fntal  .syphilis    . 
Endocarditis,  fiftal 

streptococcic,  in  fo-tus. 

tubercular         ... 
Environment,  influence  of,  upon  fntal  diseases 

intrauterine 

Epidemic  Cerf-bro-Spinal  llENiNorrrs  in  Fiktf 
Ei'iDERMOLY.sis  Bullosa  Hereditaria 
Epitrichiim 

ErONYCHIUM 

Erroneocs  Views  regarding  Antenai 
Eruption,  characters  of,  in  fa-tal  variola 
Erysipelas  in  the  Fcetus 

neonatorum 
Ery'throblasts  in  the  Fcetus 
Ery'throcytes  in  the  Fietus 
"Es.\us"   .... 
Essential  Icterus  Neonatorum 
Ether,  influence  upon  the  Fotus  . 
Etiology  of  Abortion 

congenital  goitre 

congenital  hypertrichosis 

cystic  elephantiasis 

ffietal  ascites 

fcetal  bone  disease 

foetal  death 

foetal  endocarditis 

foetal  ichthyosis 

foetal  keratolysis 

tylosis  palniiB  . 
Eustachian  Tube  of  Fcetus,  anatnmj-  of 
EusTACHirs,  valve  of,  in  fcetus 
Excretions  of  the  Fcetus 
Exercise  in  Pregnancy"  . 
Exophthalmic  Goitre,  cause  of  . 
Extrauterine  Fcetus,  death  of 

pregnancy 
Extremities  of  Fcetus,  anatomy  of 
Eye,  development  of 

Face,  in  neofcetjil  period    . 
Face  Bones,  ossification  of 
Face  of  Fcetus,  anatomy  of 
Facial  Paraly'sis  in  New-born  . 
Factor,  embryonic,  in  fcBtal  pathology 

environmental,  in  fn-tal  ]iathology 

placental,  in  fcetal  jiathology 
Fallopian  Tubes  of  Fo:tus,  anatomy  of 
Family  History  in  Antenatal  1)iac:nosis 
Family  Preyalexce,  and  ovarian  cysts 
Fat  of  the  Fcetus,  origin  of 
Father,  influence  of,  in  fcetal  malaria 

upon  fn>tal  weight 
Femur,  ossific  nucleus  in  epiphysis  of 


254 
90 

305 
174,  300 

•297 
17 


r,  10 

3 
235 
369 
19S 
209 
17t) 

2\S,  220 
74,  327 


452 

192 

.  197 

59 
139 
139 
322 

67 
269 
426 
376 
324 
300 
366 
339,  352 
427 
371 
314,  317 
320 
31S 
104 
111 
161 
475 
166 
424 

27 
120 
S4,  86 

81 

82,  85 

103 

46,  47 

1S5 

177 

179 

119 

43S 

29 

89,  147 

203 

168 

91,  92 


INDEX   OF   SUBJECTS 


513 


Finp.oiDs  OF  Uteevs,  antenatal  cause 
Filter,  placenta  as  a 
FtETAL  Ascites 

development    . 

diseases,  first  work  on  . 

giowth 

heart  beat  in  labour  pains 

ichtIi3'osis,  grave  fonii 
,,  mild  form  . 

keratolysis 

life,  contrasted  with  enibryt 
general  characters  of 
placental  influence  in 
semi-parasitism  of    . 
FtETAL  Pathology 

classification     . 

comparative 

embryonic  factor  in 

general  principles 
Fcetal  Period  of  Life     . 
FtETAI.  Peiiitoxitis 

rickets 

tubercle 
FtETlciDE,  therapeutic 
Fi£TUS,  anatomy  of 

anthrax  of 

asphyxia  of  the 

cardiac  action  in  the     . 

chemical  composition  of 

cholera  in  the  . 

circulation  in    . 

compressus 

cystic  elephantiasis  of . 

death  of  the 

diabetes  mellitus  of 

distension  of  Ijladder  in 

elephantiasis  of  tlie 

endocarditis  in  the 

epidemic  cerebro-spinal  mening 

erysipelas  in  the 

excretions  of  the 

general  dropsy  of  tlie  . 

growth  of  the    . 

liypertrophic  dilatation  of  bladder 

idiopathic  diseases  of   . 

immunisation  of 

influenza  in  the 

malaria  in  the  . 

measles  in  the  . 

medication  of  . 

movements  of  . 

nejihritis  in  the 

nutrition  of  the 

papyraeeus 

parotitis 

pertussis  in  the 

physiology  of   . 

pneumonia  of   . 

position  of  primary  lesions  in 

jiotential  morbidity  of 

purpura  of 

rallies  of 

relapsing  fever  in  the  . 

respiration  in  the 

rheumatic  fever  of  tlie 

scarlet  fever  iu  the 

33 


90,  91 
90.  91 


vxor, 
27 

181 

355 

92,  93 

4 

92,  93 

13« 

306 

315 

319 

79 

78 

78,  79 

78 

12 

174 

17 

185 

172 

7,  10 

26,  362 

335 

206 

13,  460 

99 

222 

163 

133 

147 

198 

127 

78,  424 

297 

176,  409 

223 

379 

174 

369 

218,  220 

197 

161 

288 

167 

381 

288 

195 

198 

201 

196 

476 

169,  170 

378 

145,  152 

424 

198 

198 

126 

221 

182 

179 

219 

223 

198 

143 

223 

196 


514 


ANTENATAL    PATHOLOGY   AND    HYGIENE 


FiETUs — continued. 
secretions  ol'  the 
sensation  in  the 

HCJlsis  of  .  .  . 

syiilulis  of        . 
teinjieraturc'  of 
to.xii'olofjical  states  of  tlie 
traiiniatisni  in  the 
tnlii'Viidosis  of . 
tyjilioiil  fever  in  the 
vaeeinia  in  tlie 
vai'icclla  in  the 
j-ellow  fever  in  the 

FONTANELLE  OF  GeIIDY 

Foramen  Ovale,  anatomy  of 

closnre  of,  at  birth 
FKACTURES  in  the  F<ETI'S 

in  ue\v-1jorn 
FRAGILITY  OK  Bones,  antenatal     . 
Frequency  of  Fietal  Endocarihtis 
Friedreiih'.s  Ataxia 
Functional  Changes  at  Biutii  . 

Gall-stone,  antenatal 
Gastric  Spasm,  congenital 
Gastro-intestinal  Circulation  in  the 
General  Dropsy  of  the  F(etus  . 
Genital  Organs,  diseases  of,  in  fietus 

malformations  ... 
Genital  TuiiERCLE  ... 

Germinal  Pathology 

jieriod  of  life    . 

therapeutics 
Glucose  in  Fcetal  Blood 
Glycosuria  in  the  FiETrs 
Goitre,  congenital 

e.xoiihthahnic,  cause  of 
Granuloma  of  Umuilicus 
Growth  of  Fcetus 
Gummata  in  Fcetal  Syphilis 
G^'NECOLOGY,  antenatal  factor  in  . 

diagnosis 

etiology 

juris]  irudence    . 

luorliid  anatomy 

l>rognosis 

relation  to  antenatal  ]«ithi)logy 

syniiitomatnlogy 

therapeutics 

Habitual  Fietal  De.\th  . 
h.ematemesis  neonatorum 

H;EMAT0MA  OF  SteRNO-MASTOIH  IN  NkW 
HjEMATOI'OIESIS  in  the  FffiTUS 

H^matozoon  of  Malaria 
Ha:M0GL0MX  of  the  Fcetal  Blooh 

H.EMOGLOBINURIA  NeONATORI'M     . 

Hj,mophilia,  maternal,  eti'ect  on  fetus 
of  newborn 
treatment  of     . 

H,EM0RRHAC;E  FROM  THE  UMBILICUS 
H.KMORRIIAGES  IN  THE  PLACENTA 
H.EMORRHAGIC  SYPHILIS     . 

Hair,  develoiiment  of 

"Hairy  Men" 

"Hamilton"  Bed  in  Edinpa-riui  Mate 


86,  88, 


89,  90, 


159,  160 
.  170 
217,  220 
225,  -177 
145 
259 
393 
206 
199 
194 
198 
198 
4B 
111 
133 
,  393 
4S 
48 
371 
391 
39 

69 
365 
131 
288 
384 


91,  92, 


,  85 

12 

,  10 

484 

141 

162 

374 

166 

61 

167 

234 

.  -'3 

28 


10,  419 

69 

53 

42,  164 

203 

140 

63 

286 

63 

480 

65 

398 

227 

85,  88 

322 

470 


I 


INDEX   OF  SUBJECTS 


515 


"  Haklkijuin  FoiTrs  " 
Hkad  of  FcETi'S,  anatomy  of 

new-liom  infant,  anatomy  of  . 
Hkad-movlding,  in  labour 
Hkajit,  changes  in,  in  ffrtal  syphilis 

disease  in  new-lioin  infant 

malformations  of 

maternal,  state  of  futus  in 

ntofiftal  perioil 
Heakt  of  Fcetus,  anatomy  of 

intlaramation  of 

^tnlcture  of      . 
HEAT-iiE(;ri.ATixt;  Mecuani.ssi  in  Fcett's 
Hei'Atic  Changes  at  Bir.TH 

circulation  in  the  frctus 
Heredity,  heteromorphic  . 

morbid 

of  uterine  fibroids 
Heteuomohi'hic  Hekeditv 
Hexkxmilch 

Hihekxatixg  Animals  axd  Human  Fcetu: 
Hir,  congenital  dislocation 
Hiksuties  Adnata 
HiisriTAL,  pre-maternity    . 
Hvdi:amnios 

elmracter  of  liijuor  amuii  in 

in  f'ctal  syphilis 
Hydrocephalus,  congenital 

in  fetal  syphilis 

HyDKONEI'HKOSIS  in  the  FtETUS    . 
HyDKOPHOBIA  in  Pr.ECNANCY' 
HVDHOPS  SAXaUIXOLEXTrS      . 

Hydp.orrH(ea  Gravidakum 
Hy(;iene,  antenatal 

intrauatal 

of  pregnancy     . 
Hymen,  development  of 
Hyoid  Bone,  anatomy  of  . 
Hypersiderosis  of  Fietus 
Hypertrr'hiasis  . 
Hypertrichosis  Congenita 

general 

local     .... 

lumbar 
Hypertrophic  Dilatation  of  the  Bladdei: 
Hypertrophy-,  congenital,  of  the  colon 
Hypophysis  Cerebri  of  Fcetus,  anatomy  of 

function  of       . 
Hyposiderosis  of  Pregna>xy- 
Hypospadias,  diagnosis  of 
Hypotrichosis,  congenital 
Hystrix,  ichthyosis 
Huntingdon's  Chorea 

HUTCHINSONIAN  TRIAD  OF  EFFECTS  OF  CoNGENIi'AI,  SyI 


Ichthy'OSIs,  fetal  . 

gi'ave  form 

mild  form 

hystrix 

syphilitic 
Icterus  Neonatorum 
Idiopathic  Diseases  of  the  Fcetus 
Idiopathic  Icterus  Neonatorum 
Immunisation,  fcetal,  mechanism  of 
Immunity  against  Sy'philis 

vaiiola 


307 
100 
100 
36 
ti35 


83 

no 

369 
111 
H6 

41 
130 
215 
486 
27,  28 
215 

55 
147 
49,  50 
321 
466 
400 
177 
231 
389 
237 
383 
223 
239,  422 
418,  440 
465 
463 
471 

88 
107 
149 
322 
321 
321 
326 
326 
381 
367 
105 
167 
149 

29 
326 
318 
390 
254 

177 
306 
315 
318 
238 
67 


195 

246 
194 


51G 


ANTENATAL    PATHOLOGY   AND    HVGI?:NE 


Immusitv,  transmission  to  fu-tus   . 
Impkessioxs,  niateinal,  in  fn-tal  pathology 
InCUBATIOX  of  l^STAI,  Mkaslks    . 

variola  .... 

In'KANt,  syphilis  of  the 
Infantilism  in  Wumkn,  characters 

iNFlXriuN  AND  Tl!ArMAri-M 

neonatal  .... 

Infixtions,  intranatal 

LVFI.UENZA  in  THK  l-'lETl'-s 

Ix.sriitATiON,  first,  cause  of 

IXTKSTINAI.  PitOTnVSION  INTO  UmIULKAI,  Coltl) 

Intksitne,  secretions  of,  in  the  fictus 
IxTKsriNi'.s  OF  FtETUs,  anatomy  of 

in  f.i-tal  .syphilis 
Inti:aconcei'tionai,  Peuioh  of  Geuminai,  Lifi 

InTK.VNATAL  CKrHAl.lljKMATOMA    . 

diagnosis  .... 

infections         .... 

life,  importance 

pathology         .... 

phy.siology        .... 

syphilis  .... 

traumatisms     .... 

treatment         .... 
Intrautekink  Kvir.oNMF.xr  and  Disk.\ses 

life,  changes  in  .  .  . 

divisions  .... 

patliology         .... 
Iodine,  ahscnce  of,  in  the  fi-tus     . 
Iron  of  the  Fcetu.s,  origin  of 

iRBEOtTLAlUTY  OF  FcETAL  CARDIAC  ACTION 

Jaundice,  congenital 

of  the  new-born 
Joints,  development  of      . 
Justus  Blood  Test  IN  Sv chilis  . 

Kek.\tolysis,  fretal 

neonatorum      .... 
Keratoma  Pl.\ntark 
Kidney,  in  neofu-tal  period 
Kidneys,  anatomy  of         . 

cvstir  degeneration  of 

lutal  syphilis   .... 

intlammatiou  of,  in  fn'tus 
Knee,  spontaneous  dislocation  of  . 
Knots  on  Umbilical  Cord 
Knowledge  of  Fcetal  Pathology,  limitation 

Labia  Ma.iora  and  Minora,  .Tuatoniy  of 
LAiifiui!,  effects  of,  on  head  of  fVctus 

hfad-nioulding  in  . 

jiressurc  effects  of         . 
Lackratiox,  antenatal,  of  cervix  uteri 
L.KHMK  ..... 

Lanohan.s'  Layer  of  Villus 

Lanugo,  development  of   . 

Larval  Stage  of  Congenital  Tubeiuli, 

L.\RYN.\  IN  Fcetus,  anatomy  of     . 

Law  of  Colles      .... 

of  Profeta         .... 
Lead-Poisoning  in  the  Fiktus    . 
Length  of  the  F(ETUs,  causes  of  variations 
Lesions,  placental,  lethal  cfl'cct 

jirimaiy,  in  the  futus  . 


4S3 
174 
196 
190 
225 

29 
23,  24 

t*7 

r,i 

198 
143 

81 

160 

114 

236 

9 

44 
449 


34 
226 

44 
463 
176 

84 


166 
148 
13r> 


235 

319 

72 

318 

82 

115 

383 

236 

378 

214 

121,  400 

173 

120 

101 

36 

36,  37 

32 

65 

124 

89,  90 

213 

107 

249 

246 

260 

168 

183 

182 


INDEX   OF  SUBJECTS 


517 


Lin-HAL  Kffkct  of  Placental  Lesions 
Lei'coiytes,  dcvelojiinent  in  liutus 

transmission  through  the  placenta 
Lfatoivtusis  in  the  Fcetur 
LEUKi;MiA,  maternal,  state  of  fcetus  in 
Life,  antenatal,  divisions  . 

scheme 

embryonic 

ftetal     .... 

general  characters  of    . 

gerr.iinal 

neofietal 

neonatal 
Limbs,  in  the  neofn-tal  iieriod 

of  f'l'tus,  anatomy  of   . 
Limitations  of  Knowledge  of  Fietal  T 
liteuatlt.e  of  antenatal  pathology 

congenital  goitre 

congenital  prolapsus  uteri 

fretal  lione  disease 

rigor  mortis 
LiTHOl'.EDION 

Little'.s  Disease  . 
LiVET.,  anatomy  of 

changes  in,  in  fn'tal  syphilis 

chemical  composition  of 

development  of 

in  neofretal  jieriod 
"Living  Skeletons" 
Lochia,  umhilical  . 
Long  Bones,  ossification  of 
Lungs,  anatomy 

changes  in,  in  tVetal  syphUis 

in  neof  ctal  j)eriod 
LvMi'HANGiTis  OF  Umbilicus 
Lymi'Hatiis,  develojiment  of 
Lyjiphoi'ytosis  in  the  Fcetus 

Macekatiox  in  Fietal  De.4.th 
Macrocephaly  and  Lead-Poisoning 
Malaiiia,  ftetal 

clinical  history  of 

jiathology  of    . 

treatment  of    . 
Malfobmations  and  Chloeosis 

and  fetal  diseases 

in  f'ctal  sypliilis 

in  olfspring  of  tubercular  mother 

in  offspring  of  women  suffering  from  tj'jihoid 

of  genital  organs 
treatment 

of  the  heart 

of  the  nervous  system 
Malignant  Icterus  Neonatorum 
Mammaby  Glands,  development  of 

secretion  in  the  fictus  . 
Maki!IAGe,  legal  restriction  of 

regulation  of    . 
Mastitis  Neonatobum 
M.ateknal  History  in  Antenatal  D 

impressions,  in  Petal  pathology 

phy.sical  examination  in  antenatil  diagn 

symptomatology  in  antenatal  diagnosis 

temperature,  effect  upon  fetus 
Maturity  of  Foetus 
Measles  in  the  Fcetus     . 


I'AOK 

183 

142 

157 

,    140 

•2Si 

6 

7,  10 

7,  10 

7 

78 

9,  10 

9 

7 

81 

120 

173 

3 

375 

386 

353 

413 

425 

389 

113 

232 

159 

83,  86 

83 

305 

60 

82 

111 

2.34 

83 


141 

178,  421 
262 
201 
202 
203 
204 

20 
186 
240 
215 
201 

24 

31 
370 
389,  392 

69 

90 
160 

14 
485 

54 
434 
174 
442 
439 
146 

91 
196 


518 


ANTIAATAL    PATHOLOGY   AM)    IIVOIKNK 


Mkasuiskmexts  of  Hkaii  of  Foctus 
Mkchanism  ok  Ar.uiiTiox  . 

f.i-tal  (U-iith      . 

imiimiiisiition  . 
Mkciinii'M,  aii]ii'aiancf  of  . 

loinposition  of 
Mkdicatios,  antenatal 
Mkwi-inks,  jiassaj,'!'  thiougli  jilacenta 
Mki,^;xa  Neonatohim 
Mi;.mi!i:axes  of  Kikti's,  anatomy  of 
Mexixoitis,  epidemic  eereliro-spinal,  in  fn 
Mkxstuuatiox  of  the  New-dokn 
Mercurial  Poisoxixc;  ix  the  Fietus 
Metaiiolism,  Petal,  regulation  of  . 

in  the  placenta 
Microbes,  aecunmlation  of,  in  placenta 

transniissioii  of,  tlirongli  placenta 
MrCTUKITION  Dl'RIXn  FtETAI,  LiFE 

Miliaria,  nasal,  in  intus  . 

"Missing  Links" 

MiTTELscHMERZ,  cause  of . 

Modification  of  F(etal  Disease  iiv  Ex\ 

"  Moles  "   . 

Monstrosities 

formation  of     . 

in  f'l'tal  sypliilis 

in  tlie  ollspring  of  the  phthisical 
MoRiiiD  Axatomv  of  Coxgexital  Gastric  SfAssi 

of  congenital  goitre 

of  fietal  ascites 

of  fietal  lione  (lise.isi-     . 

of  fetal  ichthyosis 

of  fu-tal  syjihilis 

of  general  futal  dropsv 

of  oliliteiati(.u  of  the  iiilc-ilnets 

of  oligohyilrainnion 
MoRiiii)  Hekeditv 
MoRBin  Processes,  age-incidence 
MoRRioiTY,  potential,  of  the  fietus 
Morbus  C(eruleu.s 
MOKI'HIXE,  effect  upon  the  fietus   . 
Mortality,  potential,  of  the  futns 
Moulding  of  the  Head  ix  Laboui; 
Mouth,  develoiiment  of 

MoVEMEXTS,  fietll 

Mui.LERiAX  Ducts,  changes  in 

MlMMIFICATIOX  IX  FlETAL  DeATH 

Musculature  of  F(etus   . 
Myelination  of  Tracts  ix  Brain 
Myotoxia  Coxgexita 
Myxedema,  congenital 

NACKESGKiBE 
N^VUS  PiLOSUS 

Nails,  development  of 
Neck  of  F<ktus,  anatomy  of 
Neokietal  Period  ok  Life 

NeuXATAL  DiACiXOSIS 

infection 

pathology,  antenatal  factor  in 

investigation     . 

nomenclature    . 

[leriod  of  life     . 

readjustments,  disturbed 
Neoxatal  Syphilis 
Neoplasms  in  the  Fietus 


101 
426 
411 
195 

m,  92 
1«1 

476 
476 

69 

125 

21S,  220 

54 
263 
64,  165 
184 
180 
181 
162 

92 
322 

26 
176 
40S 

12 
1>S5 
240 
215 
366 


358 
340,  348,  352 
308,  315 
229 
292 
364 
408 
486 
5 
179 
371 
270 
ISO 
36 
84 
69,  170 
82,  S6 
78,  424 
120 
102 
391 
305 

81 

326 

,  89,  91 

107 

9,  SO 

432 

57 

42 

33 

33 

7,  10,  34 

66 

226,  227 

174,  175 


INDEX   OF  SUBJECTS 


519 


Nepheitis,  fa?tal    . 

Neiivoi's  Maladies,  fi.-tal,  trcatm 

Nervous  System,  diseases  of,  in  ff 

in  fcetal  syphilis 
New-bokn  Infant,  asphyxia 

desquamation  in 

diseases  of 

dermatitis  exfoliativa  . 

dislocations  in 

eczema  in 

erysipelas  in 

facial  jjaralysis 

fractures  in 

hitmatoma  of  sterno-mastoid 

liaemoglobinuria  in 

hemophilia  of  . 

jaundice 

keratolysis 

mastitis  in 

melfena  in 

menstruation  in 

ledema  in 

omphalorrhagia 

ophthalmia  in  . 

pemphigus  in   . 

prematurity 

puerperal  fever 

purjmra  of  the  . 

sclerema  in 

sepsis  in 

sphygmograms  of 

syphilis  of  the  . 

tetanus 
NicoTiSM,  effect  upon  the  fcetus 

NOMENCLATUllE  OF  FlETAL  BONE  DISEASE 

of  neonatal  diseases 
"Normal"  Head  of  Fcetus 
NouitlSHMENT,  transmission  through  the  pi 
Nuileated  Red  Corpuscles  in  the  Fcetu 
NucLEON  IN  Fcetal  Blood 

in  the  placenta 
Nutrition  of  the  Fcetus 

Obelio.v,  region  of  cranium 
OiiLiTERATioN  OF  BiLE-DucTs,  congenital 
Occipito-atlantoid  Joint  in  Fcetus 
OciUPATioN  in  Precjnancy 
QiDEMA  Neonatorum 
(Esophagus  op  Fcetus,  anatomy  of 

development  of 
Olicohtdramnion 
Omentum  of  Fcetus,  anatomy  of  . 
Omphalitis  Neonatorum 
O.mphalokrhacjia  Neonatorum  . 
Onychooryphosis  in  Fcetal  Iohthyosi 
Ophthalmia  Neonatorum 
Opium,  inliuence  upon  the  fretus    . 

OllGANOGENESIS 

Os  Tribasilare 

Osmosis  in  the  Placenta 

Ossification  of  the  Clavicle     . 

face  bones 

long  bones 

of  sternum 

vertebrfe 
Osteo-chondeitis,  syphilitic 


PAOE 

378 

479 

388 

237 

'    75 

73 

6 

72 

49 

55 

59 

46 

48 

53 

63 

63 

43,  67 

72 

54 


74 
65 
51 
74 
62,  463 
59 
219 
74 
60 
138 
225 
.  57,  58 
272 
335 
33 
101 
156 
139 
141 
150 
145,  152 

46 
363 

106 

475 

74 

112 

90 

381,  406 

113 

61,  62 

65 


51 


52,  53 

269 

7,  10 

346,  349 

158 

81 

82 

82,  85 

82 

82,  88 

238 


520 


ANTKNATAI,    I'ATl  lOI.OdV    AND    HYdlKNK 


OsTEOfiENESIS  ImI'EIIKKCTA 
OSTEOI'SATHYIIOSIS 

OvAKiES  OF  FcETiTs,  aiiatomy  of 

Palpatiox  of  F(etal  Heart  Bej 
Panckeas  of  F(KTU.s,  anatomy  of 

secretions  of     . 

syi)liilis 
Paralysis,  facial,  in  now-liorn 
Pakasitism  of  Fietal  Life 
Para-thyroids,  Amition  of,  in  t! 
Parotitis  in  the  Fcetus  . 
Pahs  Commvxicaxs  of  Aoista 
Paternal  History  in  Antenat 

inlliiencf  in  fietal  malaiiii 

in  sypliilis 

uiiuii  the  weight  of  the  fo-tus 
Pathui:enesis  of  Acanthoma  oi 

ceiihalha;matonia 

congenital  absence  of  skin 

ainimtatioiis 

ele]ihantiasis    . 

congenital  gastric  spasm 

goitre  . 

hy])ertrichosis  . 

lirulapsus  uteri 
PvrHixiENEsis  ok  Facial  Paraly 

fietal  ascites     . 
asphyxia 
bone  disease 
fractures 
ichthyosis 
keratolysis    . 
sy])hilis 
variola 

general  fietal  drops}'     . 

liyi.Irainnios 

liyiiertrojiliy  of  liladder 

obliteration  of  the  bile-ducts 

oligoliydramnion 

I'laeental  htemorrhages 
Pathology-,  antenatal,  and  anati 

and  liotany 

and  dermatology 

and  emliryology 

and  general  jiathology 

and  g_ynecology 

and  legal  medicine 

and  medicine  . 

and  neonatal  ])atliology 

and  obstetrics  . 

ami  orthojiedics 

and  ]iediatrics 

and  jihysiology 

and  ])svchulogv 

and  jniblie  health 

and  surgery 
Patholooy,  antenatal,  definition 

interest  in 

journal 

lecturesliip 

literature 

novelty 

]iractical  importance    . 

relations 

sulidivisions 


ic  fietu 
L  DiAi: 

Amxu 


SIS  IN  NeW-DORN 


40,  334,  340 
335,  340 

.  im 

13t; 
]14 
160 
236 
46 
78 
165 
IflS 
112 
437 
203 
252 
168 
333 
45 
329 
396 
304 
366 
370 
325 
387 
47 
360 
412 

,  339,  350,  352 

394 

314,  317 

320 

243 

189 

294 

404 

382 

.■!64 

407 

399 

17 

17 

20 


17 
17 
22,  32 
20 
19 
21 
19 
20 
19 
17 
20 
19 
20 

12 

13 

13 

3 


16,  21 


INDEX   OF   SU13.JECTS 


i21 


Pathoi.ooy,  embryonic 
Pathology,  tVetal  . 

classification     . 

comparative 

emliryoDic  factor  in 

limited  knowledge  of   . 

placental  factor  in 

principles  of     . 

scu]ie  of 
PATiiOMKn",  germinal 
Patiioi.i>i;y,  neonatal  ;  antenatal  factor  in 

investigation    . 

nomenclatnre    . 
Pathoi.ooy  of  Blood  in  Fcetal  S 

congenital  prolapsus  uteri 

cystic  elephantiasis 

fcetal  ascites 
asphyxia 
bone  disease 
death 

endocarditis . 
ichthyosis     . 
malaria 
syphilis 
tuberculosis  . 
tyjilioid 

general  fretal  dropsy    . 

lieart  in  fetal  syphilis 

hyriramnios 

hypertro]ihy  of  bladder 

obliteration  of  the  bile-ducts 

jilacenta  in  syphilis 

placental  lisemorrhages 

tylosis  ]ialm!e  . 
Pkculiakities  of  Fcetal  Morbid  States 
Pelvis  of  Fcetus,  anatomy  of 

development  of 
Pkmi'Hicus,  antenatal 

neonatorum 

syphilitic 
Peptonukia,  in  pregnancy 
Pekiartf.eitis  in  Fa:TAL  Syphilis 
Peritonitis,  tVetal 
Permeability,  placental  . 
Perxicious  Icteric  Cyanosis 
Persistence  of  Fcetal  Cardiac  Activi 
PERTrssis  IN  the  Fubtus  . 
Petrification  of  Dead  FiETUf 
Phosphates  in  the  Fcetus 
Phosphorus  in  the  Placenta 

poisoning  in  the  fnetus 
Phy'sical  Examination  in  Antenatal 
Phy-sical  Signs  of  Hydramnios 
Physiological  Readjustment  at  Birth 

traumatism  of  birth 
Physiology  of  the  Fcetus 

of  mother  in  pregnancy 

of  neof  etal  period 

of  neonatal  life 
PiLOSISM      . 

Pituitary  Body,  functions  of,  in  fcetus 
Placenta,  allantoic 

anatomy  of 

changes  in  fcetal  death 

chemical  composition  of 

circulation  in  the 


337,  339, 


PAGK 
12 

12 
174 
17 
185 
173 
179 
172 
172 
12 
42 
33 
33 
235 
385 
298 
358,  360 
.  412 
342,  348,  352 
176,  420 
.  371 
308,  315 
203 
229 
212 
9,  201 
292 
235 
403 
381 
364 
230 
399 
318,  319 
176 
116 
87 
327 
74 
227,  238 
419 
235 
236,  362 
182 
64 
134 
198 
425 
149 
151 
265 
442,  444 
401 
38,  39 
35 
126 
127 
80 
34 
322 
167 
154 
122 
423 
150 
127 


522 


ANTKN.MAI.    I'.VniOLOCIY    AND    HVCJIKXK 


Placenta — cnntln  ued. 

comparative  Iiistology  of 

connections,  in  ncolVi-tal  iieriotl 

developnient  of 

disease  of,  tii'atment  of 

excretion  tlirougli  tlie  . 

iiliro-fatty  degeneration  of 

in  f(etal  anthrax 

in  fietal  sypliilis 

in  general  fotal  dro]isy 

liaimorrliages  in  the 

lesions  of,  lethal  elfect 

life  history  of  . 

metabolism  in  the 

nutritive  functions  of  . 

pathology  of,  in  cdaniiisia 

separation  of  the 

sepsis  of  .  .  . 

teratology 

toxicitj'  of        . 

tuberculosis  of 

vessels  of 

vitelline  or  omphaloidean 
PXEVMONIA,  fcetal  . 

in  foetal  syjiliilis 
Poisons,  efl'ect  of,  on  the  fu-tus 

storing  up  of,  in  placenfci 
Polytrichia 

Post-mortem  Chaxoes  ix  the  Fcetus 
postxatal  diagxosis 

pathology 

treatment  of  antenatal  morbid  state 
Potential  Morbidity  of  Ixtrauterixe 
Pregnancy,  diet  in 

exercise  in        . 

extrauterine 

liydropholiia  in 

hygiene  of        . 

occupation  in    . 

physiolog}'  of  . 

vaccination  during 
Pregnant  Women,  hospitals  for  . 
Pre-Materxity  Hospital,  plea  for 
Premature  Infaxts 
Premature  Labour 

in  fretal  death  . 
Pressure  Effects  of  Labour 
Prevention,  antenatal 
Prochownick's  Diet  in  Pregxancy 
Profeta,  law  of     . 
Prognosis  ix  Fcetal  Exdocarditis 
fretal  ichthyosis 

hydramnios 

obliteration  of  the  bile- ducts   . 
tylosis  palniiB  . 
Projectiox  of  Antenatal  into  Postx 
Prolapse,  congenital,  of  uterus     . 
Propuvlaxis  of  Tubercle 
Protection  of  the  Fcetus  by  the  Placi: 
"  Ptebiox  "  Regiox  of  Skull 

PlERICULTURE 

rfERpKp.AL  Fever  of  the  New-borx 
Pulmonary  Circulation  ix  the  Fcetu 
Pulse  of  Fiktus,  characters  of 
Pupillary  Membraxe,  development  of 
Purpura,  fa?tal 


SS,  89; 


90,  91 


1S2 
84 
92,  93 
479 
163 
399 
2-J2 
230 
294 
398 
183 
122 
184 
155 
281 
37,  38 
217 
17 
281 
181,  209 
123 
154 
221 
234 
259 
180 
321 
178 
450 
5 
461 
179 


223 
471 
475 
127 
194 
470 
466 

62,  463 

455 

427 

36,  37 

14,  19 

473 

246 

373 

314 

403 

365 

319 

2 

25,  384 
216 
180 
104 

13,  465 
59 
130 
137 
90 
219 


I 


INDEX   OF  SUBJECTS 


523 


PvLORUS,  congenital  li3-iiertrojiliic  steuosis  of 
PvocYAN'io  Disease,  immunity  against    . 


I'AQB 

365 
195 


QflCKEXIXC. 


Rabies,  Fovtal 
Rachitis  Coxgexita 

f<etal     .... 
Rarity  of  Fietal  Tuberci'losis  . 
Rate  of  Fcetal  Heart  Beat 
Readjustments,  neonatal,  distinbed 

liliysiological,  at  liirtli 
Rectum  of  Fcetus,  anatomy  of     . 
Kicnioxs  OF  the  Spixe  IX  the  FoiTUS 
ReiUstratiox  of  Still-Biuths    . 
Rr.i.APsixu  Fever  ix  the  Fietus  . 

RksI'IIIATIOX  IX  THE  FlETl'S 

intrauterine 
pulmonary,  cause  of    . 
ReSI'IRATORY  MoVEMEXTS  of  F(ETUS 

Retention  of  Dead  Fletus 
Rheumatic  Fever  in  the  Fietus 
Ribs  of  Fietus,  anatomy  of 
Rii:iDiTY,  congenital  spastic 
RiGiiR  JIoRTis  IN  the  Fcetus 
RiTTEu's  Disease  . 


223 
335 
335 
210 
135 

66 
3S,  39 
119 
106 
464 
198 
143 
169 

40 
144 
427 
223 
109 
389 
178,  413 
.  63,  72 


Sacrum  of  Fcetus,  anatomy  of 

ossification  of  . 
Salivary  Glands,  clianges  in  the  neofn'tal  jieriod 

secretion  in  the  fivtus  . 
Salts  ix  the  Fietal  Blooh 
"Sanatoria  de  Geossesse " 
Sapoxificatiox  of  Dead  Fcetds 
Scapula  of  Futus,  anatomy  of 
Scarlet  Fever  in  the  Fietus 
Scheme  of  Axtexatal  Life 
Sclerema  Neoxatorum    . 
Scope  of  Axtexatal  Diagnosis 
Sebaceous  Glaxds,  development  • 

secretion  in  tlie  fcetus  . 
Secretioxs  of  the  Fcetus 

of  the  placenta 
Sensation  in  the  Fcetus  . 
Separation  Results  of  Birth 
Sepsis,  fetal 

neonatorum 
Serous  Membranes,  secretions  of,  in  tlie  foetus 
Serum  Test  for  Fcetal  Typhoid 
Sex,  microscopically  recognisable  in  neofcetal  period 
Sexi'al  Glaxds,  development  of  . 
Shoulders  of  Fcetus,  measurements  of    . 
Sigmoid  Flexure  of  Fcetus,  anatomy  of 
Sixgultus,  fcetal    .... 
Sixus  of  Meckel  of  Placenta    . 
Skeleton,  fetal,  diseases  of 
Skiagraphy  ix  Axtexatal  Diagnosis    . 
Skix',  congenital  absence  of 

development  of  .  .  . 

in  fcetal  syphilis 
Smallpox  ix  the  Fcetus  . 
Spasm,  gastric,  congenital  . 
Sphygjioorams  of  New-born  Ixfaxt 
Spixa  Bifida  and  Coxgexital  Uterixe  Prolapse 


.  117 
.   107 

82 
.  159 
.  141 
.  470 
.  424 
.  109 
.  196 
.  7,  10 

74 
.   431 

88 
.  160 
159,  160 
.  158 
.  170 
.  37,  38 
217,  220 

60 
.  160 
.   200 

82 

82,  86,  87,  90 
.  109 
.  115 
144,  169,  441 
.  123 
237,  334 
.  448 
.   328 

85 
238 
176,  188 
.  365 
.  138 
.   387 


524 


ANTKNAJAl.    I'A  TIIOLOC^'    AND    PnXMENE 


' 


SriXAl,  Coiti)  IX  I'lKiTs,  anatomy  of 

development  of  .  .  . 

SriKE  OF  FiETUs,  anatomy  of 
Si'iiiALiTV,  fii'tal,  of  Falloiiiun  tulic.-- 
Si'l,KEX  OF  FovTf.s,  anatomy  of 

in  syphilis        .... 
St.  Kilda,  the  .scourge  of  . 
Stexosis  of  Pylokus,  congenital  hypiTtiophic 
Steiixvm  of  F(ETr.'i,  anatomy  of   . 

ossification  of  . 
Stikkage    ..... 
Stomach  ok  Fikti'.s,  anatomy  of    . 

contents  of        .... 

development  of  .  .  . 

StouiXG  Ul'  OK  SviWTAXf'ES  IX  THE  Pl.ACEXTA 

Stkuma  Coxgexita 

"  suckixg-pabs  "  ix  fcetus 

SuDOKiPAEors  Glaxds,  develojinient  of    . 

Sugar  in  the  Lkjuor  Amxii 

SuLPHUKK^  Acid,  poisoning  with,  in  ])regnancy 

SuritA-KEXAL  Capsule.s  of  FtETU.'i,  anatomy  of 

development  of 

functions  of      . 

in  syphilis 
Sylviax  Fissure   . 
Symptomatic  Icterus  Neoxatorum 
Sy-mptomatologv  of  Coxgexitai.  Ki.eph. 

of  congenital  gastric  spasm 

of  congenital  goitre 

of  congenital  liyjicrtrichosis 

of  congenital  prolapsus  uteri    . 

of  f'etal  ascites 

of  ffletal  bone  disease     . 

of  ffctal  death  . 

of  fictal  ichthyosis 

of  fietal  keratolysis 

of  general  ffetal  drojisy 

of  hydramnios  . 

of  obliteration  of  the  bile-ducts 

of  oligohydramnion 

of  tylosis  jialma; 
Svxcvtiu.m  ok  Villus 

SYXOXYMs  UK  CnNKINITAL  H  VPE  RTRICHOS 
of  f.f^ll   irlitllV.isis 
of  fn/tal  li.k.-ts 

Syphilis,  embryonic 
Syphilis,  F(Etal,  diagnosis 

dystrophies 

effects  .... 

limitation  of    . 

morbid  anatomy  of 

nature  of  causal  agent  of 

]iathogenesis  of 

placenta 

tran.snii.ssion     . 

treatment 

Tail,  in  the  neofiptal  jieriod 
"Tails"     .... 
Teeth,  development  of 

formation  of,  in  ncofcital  )ieriod 

in  congenital  hypertrichosis     . 
Telegoxy,  mechanism  of  . 
Temperature  of  the  Fcetus 

of  the  liquor  amnii 
Tekatogexesis 


I-AOK 

106 

$:>,  88 

106 

30 
114 
23B 

57 
365 
109 

S2 
169 
113 
160 
86,  87 
158 
374 
103 

88 
223 
267 
115 

S6 

166 

236 

S2,  87 

67 
303 
366 
376 
324 
386 
357 
39,  348 
415 
307,  315 
320 
290 
401 
363 
408 
319 
124 
321 

7,  315 
335 
228 
238 
239 
254 
225 
229 
244 
243 

8.  230 
245 

7,  477 

81 

326 

89,  91 

82 
324 
185 
145 
146 

17 


INDEX   OF   SUBJEC'IS 


Teuatolooical  Rkcokiis  ok  Chaldka 
Teratology 

comparative 

isolated  position 

of  plants 

TeR ATOM ATA 
TK.r.ATOSCOI'Y 

Tes'I'KLe,  descent  of 
in  fii'tal  sypliilis 
Tetanus  Neoxatokum 
Tiii'.ORV,  Bauuigaiten's,  of  lateucj' 

TlIEIlAl'ElTlr  FtETRTDE       . 

Tuekapeutr'S,  antenatal  . 

germinal 

of  fffital  diseases 

of  malformations  of  genitals  . 
Third  Generation,  syphilis  of  . 
Thomsen's  Disease 
Thoracic  Duct  of  Fietus,  anatomy  of 
Thorax  of  Foetus,  anatomy  of  . 
Thromdo-arteritis  of  Umrilicus 
Thymus  of  Fietus,  anatomy  of     . 

changes  in,  in  f  t-tal  syphilis    . 

development  of 

function  of       . 

in  neofiital  period 

physiology  of   . 

regulator  of  growth 
Thyroid  Gland  in  Fcetus,  anatomy  of 

development  of 

enlargement  of 

function  of        . 

hypertrophy  of 

in  neotVetal  period 

regulator  of  metaliolism 
Thyro-mucoin  in  F(etal  Thyroid 
Tobacco  Poisoning,  effect  upon  the  fcetui 
Tonsils,  development  of    . 
Torsion  of  Umbilical  Cord 
Torticollis,  congenital     . 
Toxicological  States 
ToxiNES,  transmission  through  the  placenta 
Trachea  in  Fcetus,  anatomy  of   . 

development  of  . 

Transition  Changes  in  Neofcetal  Pei 

organism 

traumatic,  of  1  lirth 
Transmission  of  Diseases  from  Fietus 

of  fVetal  malaria 

of  microbes  through  the  placenta 

of  substances  from  fcetus  to  raotlicr 

of  syphilis,  mode  of     . 

through  the  liquor  amnii 

through  the  placenta   . 
Trau.matk;  Morbid  States  of  the  Fietu 
Traumatism  and  Infection 

intranatal         .  . 

Treatment  of  Congenital  Dislocation 

elephantiasis    . 

gastric  spasm    . 

hypertrichosis  . 

fii'tal  ascites 

death    .... 

endocarditis 

keratolysis 

nervous  maladies 


175,  1 


12 

17 

(i 

17 

174 

i 

90,  91 

237 

57,  58 

213 

13 

14,  15 

484 

451 

30,  31 

254 

391 

112 

83,  108 
62 

109 
235 

86 
164 

83 

484 

164 

107,  108 

86 
374 
164 
165 

83 
165 
166 
272 

87 
120,  400 

53 
175,  259 
157 
107 

87 

83 

80 

35 

84,  188 
203 
181 
163 
244 
181 
156 

5,  393 
23,  24 
35,  44 
50,  51 


325 
362 
428 
373 
320 
479 


520 


ANJl-.NAl'AI.    I'A'llIOl.OdY    AM)    inciKNK 


TitEATMENT— C'/H</)ll(((/. 

syi.hilis 

fjfiicral  fiital  ilrojisy     . 

liii'iiiogiliiliit 

liydianiiiios 

intranatal,  nf  fn-tal  disease 

oliliteratioii  of  tlie  liile-ilucts    . 

rtcmreiit  placental  disea.se 

tylosis  i)ahuic   . 
TitKMOH,  hereditary 

TltlliASILAR  BOXE  IN  FlKTAI.  KllKETS 

Trkhauxis 

TltllHOSTASIS 

TUBKRCLE,  iVetal,  bacteriology  of  . 

cases  of  .  .  . 

characters  of    . 

dystroi)hies  of . 

eWdencc  of  existence  of 

heredity  in       . 

latency  of         . 

malformations  in 

liathology  of    . 

jirophylaxis  of 

rarity  of 

TUBKItCrLOSIS  OF  THE  FfETUS 

of  the  placenta 
Tr.Morns  hf  Fietus 

genital  organs  . 
Twis-BEAHIXG,  lieredity  of 
Twins,  dilference  in  tenijierature  of 

syphilitic  infection  in  . 

variola  in         . 
Tylosis  Palm^  et  Plant.e 
Tympanic  Cavity  of  Fietus,  anatomy  of 
Tyi'hoid  Fever  in  the  FtETUs 

serum  test  in    . 

Ui.CEU,  congenital  . 

umbilical 
Umbilical  Arteries,  anatomy  of 
cord,  anatomy  of 
development  of 
intestine  in  . 
morbid  conditions  of 
syphilis  of     . 
lochia  .... 
vesicle,  function  of 
vessels,  changes  in,  at  liirtli 
Umhilicu.s,  blenorrhcca  of  . 
granuloma  of  . 
hajmorrhage  from 
lymphangitis  of 
ulcer  of  .  .  . 

Uracih-s  of  Fcetus,  anatomy  of    . 
Urea  in  Fcetal  Bluod 

I'llKIKIl  .... 

Ureters  of  Fietvs,  anatomy  of   . 
Urethra  of  Fcetis,  anatomy  of  . 
Urinary  System,  diseases  of,  in  f'ctus 
Urine,  fretal 

clieniical  composition  of 

excretion  of      . 
Uterus,  changes  in,  in  IVetal  death 

congenital  jirolapse  of  the 

fietal,  anatomy  of 

pregnant,  tenipeiature  of 


■-'97 
.   480 

406 
.  463 
.  365 
.  479 
.  319 
.  300 
34t),  349 
.  321 
.  325 
181,  208 
207,  208 
.  212 
.  214 
.   207 

215 
.  213 
.  215 
.  208 
.  216 
.  210 
.   206 

209 

.   175 

25 

.   438 

146 
.  247 
.   190 

318 

104 
.  199 
.   200 

329 
62 

116 

112.  120 

88.  90,  91,  92 

81 

400 

231 
60 

154 


62 

62 
112 
141 

82 
116 
120 
378 

92 
162 
161 
425 
384 
119 
146 


INDEX   OF  SUBJECTS 


A'aCCISATION  of  the  F(ETUS 

Yagin'a  ok  Fcetus,  anatomy  of 

development  of 
Vaoixal  Glands,  secretion  of,  in  the  fietus 
Vacitus  UTEraNUs 
VALrE  OF  F(ETAL  LiFE,  estimation  of 

relative 
Varicella  in  the  Fcetus 

VaKIOLA  of  FtETVS 

clinical  history 

comiilications    . 

diagnosis 

ernption 

iuculiation  jieriod 

jiathogenesis     . 

prognosis 

stages   .... 

treatment 
Veexix  Caseosa,  composition  of  . 

development  of 
VEKTEnnAL  CoL^■MX  OF  FtETUs,  anatomy  of 

ossification  of  . 
Vesicle,  umbilical 
A'essels,  changes  in,  in  fretal  syphilis 

congenital  atheroma  of 

vitelline 
Vestibvlah  Baxd  is  F<ETr.s 
ViEUSSENS,  linilms  of 
A'illi,  changes  in  structure  in  pregnancy 

chorionic,  structure  of 
Vitelline  Cieculation  ix  Neofietal  P 

placenta  ... 

A'OLVi'Lrs,  congenital 

Wegxkr's  Sigx  of  Fietal  Syphilis 
Weight  of  the  Fietus,  causes  of  variations 
Whaktux's  Jelly  of  Umbilical  Cord 
V'idal  Sekum  Test  for  Typhoid 
Winckel's  Disease 
WoLFFiAX  Bodies,  development  of 
■'VouKDS  of  the  Fcetus 

XaNTHOCYTES  IX'  THE  FcETUS 

Yellow  Fever  ix  the  Fcetus 
YuLK-sAc,  function  of 


527 

I'AUK 

193,  194 

119 

87,  89 

160 

143 

455 

457 

198 

176,  188 

189 

192 

193 

192 

190 

189 

193 

192 

193 

160 

!9,  91,  92 

.   106 

',  88,  106 

83,  154 

.   235 

.   374 

154,  155 

120 

111 

38 

124 

83 

154 

367 

237 

168 

121 

200 

63,  64 

82,  86 

178,  395 

.   139 

.   198 
.   154 


PRINTED   BY 

MORRISON  AND  GIBB  LIMITED 

EDINBDRGH 


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